Vascular Dementia

What is Vascular Dementia?

Vascular dementia is a medical term that describes a decline in cognitive abilities including memory, planning, reasoning, and judgment. When blood flow is reduced to any region of the brain, it becomes damaged quickly and recovers slowly, if at all. Damaged brain tissue causes the dementia symptoms. When symptoms are severe, they impair a person’s daily functioning and may affect their ability to live independently. In that case, family caregivers may need to help manage their loved one’s care.

Symptoms of vascular dementia can begin gradually or abruptly. For example, memory and thinking problems often appear immediately after a patient has a stroke. However, having a stroke does not necessarily mean that a person will have dementia: The severity of the stroke and location in the brain determines if thinking skills are significantly affected. On the other hand, some individuals will exhibit gradual and subtle changes due to chronic cerebrovascular disease (i.e., conditions that affect the blood vessels in the brain). Vascular dementia frequently occurs with other types of dementia, such as Alzheimer’s disease or Dementia with Lewy Bodies. The additional presence of vascular disease in the brain often makes symptoms of other brain diseases worse. 

Facts

Vascular dementia is the second most common cause of dementia after Alzheimer’s disease. Incidence estimates range from 10-20% of all dementias among older adults. Vascular dementia results from reduced blood supply to the brain due to diseased blood vessels. To be healthy and function properly, neurons require adequate oxygen, glucose, and other nutrients provided by blood that is delivered to the brain through a complex system of vessels (the vascular system). If this vascular system becomes compromised by weak or blocked vessels, then blood supply will not be adequate and brain cells and tissue will be damaged and/or die.

Certain diseases and conditions that narrow or cause long-term damage to blood vessels can increase one’s risk of developing vascular dementia because they may lead to stroke or multiple subcortical infarcts (tissue death due to inadequate blood supply). These conditions may result from aging, genetic factors or from various medical disorders that contribute to underlying cardiovascular diseases. They include:

• high blood pressure
• hardening of the arteries (atherosclerosis)
• diabetes
• sleep apnea
• high cholesterol
• obesity
• smoking
• atrial fibrillation
• physical inactivity and poor diet.

Types of Vascular Dementia

Vascular dementia can be divided into two types: post-stroke dementia and multi-infarct dementia (also known as subcortical vascular dementia).

POST-STROKE DEMENTIA

Symptoms are most obvious when they arise suddenly following a stroke, resulting in the blood supply to the brain being suddenly interrupted due to a blocked artery. This disruption can lead to damage or death of brain tissue. Not all stroke victims develop dementia; it is estimated that approximately 20% of stroke patients develop post-stroke dementia within six months. Post-stroke dementia can result in physical symptoms (for example, paralysis or weakness of a limb) and/or problems with vision or speech. Symptoms depend on what area and how much of the brain is affected.

MULTI-INFARCT DEMENTIA

This type of dementia results from a series of mini-strokes in vessels located deep within the brain (i.e., subcortical). These mini-strokes may not lead to any sudden obvious onset of symptoms; however, even these “silent brain infarctions” still increase the risk of dementia, a result of disease of the brain’s blood vessels. Over time, the effects of this damage can result in dementia. Progression is referred to as “step-wise” because symptoms worsen after any additional mini-strokes and then remain the same for a time. Symptoms that may develop include changes in reasoning and other thinking skills such as memory, as well as mood and behavior problems, including depression and apathy.

Symptoms and Disease Course

Symptoms differ depending on what part and how much of the brain is affected, and can overlap with those of other types of dementia. Symptoms are likely to be more gradual and less dramatic in multi-infarct than in post-stroke dementia. For example, in multi-infarct dementia a gradual decline in some aspects of speech and language may be noticed, whereas immediately following a stroke there can be a sudden change in speech.

Vascular dementia does generally progress, but the speed and pattern of cognitive decline, motor skills slowing, and mood changes can vary. Some individuals may experience memory loss, whereas others may exhibit changes primarily in mood and behavior.

Like all dementias, individuals in later stages will show overall cognitive changes and will depend on others for care. Symptoms common in both post-stroke and multi-infarct type dementia can include:

• confusion and difficulty problem-solving
• trouble paying attention and concentrating
• problems with learning and memory
• poor planning and organizing 
• changes in mood including loss of interest in regular activities
• trouble finding the right word
• motor symptoms including clumsiness and slow or unsteady gait disturbance.

Family caregivers may find it difficult to know how to provide help when symptoms are so variable. Getting a definitive diagnosis will make it easier to provide care now and in the future.

Testing and Diagnosis

Concerns about vascular dementia should be raised with a physician. Early diagnosis is important, as it provides access to treatment, advice regarding planning for the future, and possible recommendations for lifestyle changes that may slow down the progression of the underlying disease. Recommended lifestyle changes may include following a healthier diet, getting physically active, quitting smoking, and quitting or decreasing alcohol consumption.

Depression frequently coexists with vascular dementia and can contribute to, or worsen, vascular-based cognitive symptoms. Medical conditions that may present symptoms similar to depression (fatigue, irritability, insomnia, decreased appetite, anxiety) caused by vascular disease should first be ruled out.

A thorough medical examination for vascular dementia can include a variety of different tests and studies. A physician will conduct a full medical history and likely order blood tests to rule out reversible causes of cognitive decline, such as low Vitamin B12, or hypothyroidism. Often individuals are referred to a neurologist for more specialized examination of motor functioning, as well as reflexes, sensation, and gait (manner of walking). A brain scan (e.g., CT, MRI, MRA) is often ordered in the examination stage to identify the presence of strokes or disease in the blood vessels.

Some individuals may also be referred for a carotid ultrasound if there is concern about blockages in these specific arteries. Referral to a specialist for evaluation of thinking skills such as memory and processing speed is typical and an important component of the evaluation. The specialist consulted may be a psychiatrist or neuropsychologist. Evaluating independent function is important to determine if the cognitive difficulties are impacting day-to-day activities enough to indicate a diagnosis of dementia. Patients who have cognitive decline but intact daily functioning might instead be given a diagnosis of Mild Cognitive Impairment (MCI).

If the medical examination indicates the person has dementia or MCI due to vascular disease of the brain, the diagnosis will be made and discussion about the next steps will be provided.

Vascular dementia can be difficult to differentiate from other forms of dementia because there is frequently an overlap in symptoms. Also, many individuals with dementia have both vascular disease and another brain disease such as Alzheimer’s or Lewy Body Dementia, and therefore have a “mixed dementia.” Mixed dementia may be diagnosed less frequently than vascular dementia or Alzheimer’s disease, but many researchers believe it is quite common and deserves greater attention because the presence of two or more types of dementia-related conditions is likely to have a more severe impact on the brain and cognitive functioning than one type alone. 

Treatment

There is no specific or approved treatment for vascular dementia. Controlling medical conditions that impact cardiovascular health is recommended to prevent further decline. For example, medications to control blood pressure, cholesterol, heart disease, and diabetes can be prescribed. Aspirin or other drugs may be prescribed to prevent clots from forming in blood vessels.

An individual diagnosed with vascular dementia will also be encouraged to incorporate a healthy lifestyle. A diet with plenty of fruit and vegetables, fish, and limited fat and salt is important. Exercising and avoiding smoking and alcohol can reduce the risk of further strokes or vascular brain damage.

Research suggests that medications currently available for treating Alzheimer’s disease can, for some, be effective in treating symptoms of vascular dementia. These drugs may slow progression of cognitive symptoms such as memory decline, but they will not cure the disease or prevent additional deterioration. These drugs include the class of drugs called cholinesterase inhibitors and include donepezil (Aricept), rivastigmine (Exelon), and galantamine (Razadyne). It’s important to consult with a physician about starting these medications, as there are common side effects that need to be discussed and monitored.

Caregiving and Vascular Dementia

There are many ways to help your family member or friend maximize his or her independence and cope with the cognitive symptoms of vascular dementia. Unlike Alzheimer’s disease, individuals with vascular dementia might better remember things in their daily life when repetition and context are provided. Likewise, simple cues can jog recall when remembering is difficult for the person. Structured and predictable routines can be helpful. Assistive devices and technology, such as pill boxes or electronic reminders on a phone, might be useful as well.

Breaking down complex—now overwhelming—tasks into smaller and more manageable steps will make them easier to complete. It’s also useful to simplify explanations and directions. As the disease progresses, even tasks learned years ago, like shaving or brushing teeth, may require step-by-step directions.

Problems with attention can make  focusing and concentrating more difficult for your family member. Ensuring an environment that is not overly busy or noisy will make it easier to pay attention. Multi-tasking can be particularly difficult. Individuals with vascular dementia might have an easier time completing tasks when they focus on a single activity at a time, instead of dividing their attention between multiple tasks. 

Changes in mood and personality can accompany cognitive changes in vascular dementia, and often, these changes are the most distressing for caregivers. Approaching these behaviors with the understanding that they are a result of changes in the brain, as opposed to a choice that a healthy person would make, can help guide how to best respond and manage them. Some specific tips include:

1. Identify possible reasons for the behavior change. Examine the situation to determine if there was some behavioral trigger or antecedent to the change. For example, consider when, where, with whom, and what the person with dementia is being asked to do. This may promote a deeper understanding of their response/reaction and help you identify ways to calm the individual and decrease future disruptions. Keep in mind that the person may be less capable of expressing their distress adequately if they are experiencing pain or discomfort. Caregivers can often use the individual’s behaviors as indications of distress.
2. Consideration of safety concerns can guide your response. While many behaviors can be distressing and bothersome for caregivers, they are not necessarily a safety risk for someone with vascular dementia. Alternatively, some behaviors can be potentially dangerous for the individual with vascular dementia and/or the caregiver. For example, aggression and wandering may require immediate intervention, such as installing locks on the door and developing a safety plan. Disruptive but not dangerous behaviors, such as repetitive questioning or pacing, may respond to a softer approach, such as engaging in another activity as a distraction.
3. Practice patience, acceptance, and flexibility. Remember that emotional outbursts and personality changes are due to underlying brain disease and are not a deliberate response or reaction to you as the caregiver. When behavior problems become overwhelming to the family, it’s critical to seek out support. Caregiver support groups are helpful, offering a space to vent, grieve, and gain practical advice from others who are experiencing similar challenges. Exploring other sources of respite, such as adult day programs, can also be beneficial, both for the individual and for caregivers.

Resources

Family Caregiver Alliance
National Center on Caregiving
(415) 434-3388 | (800) 445-8106
Website: www.caregiver.org
E-mail: info@caregiver.org
FCA CareNav: https://fca.cacrc.org/login
Services by State: https://www.caregiver.org/connecting-caregivers/services-by-state/

Family Caregiver Alliance (FCA) seeks to improve the quality of life for caregivers through education, services, research, and advocacy. Through its National Center on Caregiving, FCA offers information on current social, public policy, and caregiving issues and provides assistance in the development of public and private programs for caregivers. For residents of the greater San Francisco Bay Area, FCA provides direct family support services for caregivers of those with stroke, Alzheimer’s disease, ALS, head injury, Parkinson’s, and other debilitating health conditions that strike adults.

FCA Fact and Tip Sheets

A listing of all FCA fact and tip sheets is available online at www.caregiver.org/fact-sheets.

Caregiver’s Guide to Understanding Dementia Behaviors
Caregiving at Home: A Guide to Community Resources
Dementia, Caregiving, and Controlling Frustration
Dementia: Is This Dementia and What Does It Mean?
Hiring In-Home Help
Home Away from Home: Relocating Your Parents 
Mild Cognitive Impairment (MCI)
Ten Real-Life Strategies for Dementia Caregiving
Hospital Discharge Planning: A Guide for Families and Caregivers

Other Organizations and Links

National Stroke Association
www.stroke.org
The National Stroke Association provides education, information and referral, and research on stroke for families, health care professionals, and others interested in or affected by stroke.

American Stroke Association
www.strokeassociation.org
The American Stroke Association offers information and sponsors programs and support groups throughout the nation for stroke survivors and family members.

American Heart Association
www.heart.org
The American Heart Association provides public health education to community members, healthcare professionals, and to lawmakers and policymakers.

National Institute of Neurological Disorders and Stroke
www.ninds.nih.gov
The National Institute of Neurological Disorders and Stroke supports and performs basic, translational, and clinical neuroscience research through grants-in-aid, contracts, scientific meetings, and through research in its own laboratories, and clinics.

This fact sheet was prepared by Deborah Cahn-Weiner, Ph.D., ABPP and Anneliese Radke, Psy.D. of the Uuniversity of California Davis Alzheimer’s Disease Center. © 2018 Family Caregiver Alliance. All rights reserved.