3-A Vascular Dementia
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3-A Vascular Dementia

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3-A Vascular Dementia 3-A Vascular Dementia Presentation Transcript

  • Vascular Dementia – biopsychosocial aspects! Dr Maryam Hussain Dr Cornelia van Ineveld March 11 th , 2008
  • 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
      • 6 months 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
    • Past history:
      • Diabetes Mellitus Type II
      • Hypertension
      • Osteoarthritis (knees)
      • Cataracts
    • Meds:
      • Glyburide (diabetes)
      • Metformin (diabetes)
      • Enalapril (high blood pressure)
      • Hydrochlorthiazide (high blood pressure)
      • Aspirin
  • Cognitive testing:
    • MMSE 18/30 (normal ≥24), 0/3 recall
    • Clock: All numbers spaced on right
    • Verbal fluency 4 (normal 10)
    • Impaired naming
    • Difficulty following complex commands
    • Anxious, repetitive, notable word finding problems
    • Mild paranoia
  • 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
    • CT
      • 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)
  • Diagnosis
    • Mixed dementia
      • Clinical features of Alzhiemer’s 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
  •  
  • Objectives
    • What is Vascular Dementia (VaD)?
    • Different types of VaD
    • Neuropsychiatric manifestations
    • Risk factors & common presentations
    • Diagnostic tests
    • Treatment options
  • Dementia
    • Common condition , especially in the oldest old groups
    • Diagnosis
      • memory impairment
      • impairment in other cognitive domains
      • progressive
      • impairment in functional status
    • Associated with considerable morbidity and mortality
  • Types of dementia
    • Alzheimer's dementia (AD): 60%
    • Vascular dementia (VaD): 15-20%
    • Lewy Body dementia 10%
    • 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
  • History…. (just for fun!)
    • 17 th century – 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
  • Language, language, language
    • Vascular Dementia
      • 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!
  • Vascular Dementia
    • Generally clinicians look for
      • Stepwise progression, prolonged plateaus or fluctuating course
      • Focal cognitive deficits but 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
  •  
  • Objectives
    • What is Vascular Dementia (VaD)?
    • Different types of VaD
    • Neuropsychiatric manifestations
    • Risk factors & common presentations
    • Diagnostic tests
    • Treatment options
  • Clinical Categories
    • Large Vessel Vascular Dementia
    • Small Vessel Vascular Dementia
    • Ischemic-Hypoxic Vascular Dementia
    • Hemorrhagic dementia
  • Large Vessel
    • Post-stroke dementia/ Multi-infarct dementia
      • Dementia developing after multiple completed infarcts
      • Significant proportion of post-stroke dementia remains undiagnosed
    • Strategic stroke
      • 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
  •  
  •  
  •  
    • Incidence estimates (3 months post CVA) vary: 25-41%
    • Clinical features will depend largely on what part of the brain was damaged
    • Depression common
    • Location of vascular lesion is likely more important than how much tissue died
  •  
  • Why do some patients with stroke have cognitive impairment and others don’t?
    • Risk factors for post-stroke VaD:
    • Older age
    • Lower education
    • Recurrent stroke
    • Left hemisphere stroke
    • Trouble swallowing, gait changes and urinary incontinence
    • Acute complications of stroke (seizures, cardiac arrhythmias, aspiration pneumonia etc)
  • Small Vessel Disease
    • Frontal lobe deficits
    • Executive dysfunction
    • Inattention
    • Depressive mood changes
    • Changes in gait
    • Parkinsonism
    • Memory impairment is less pronounced
      • More sub-acute course
  •  
    • Magnetic resonance image of the brain, T2 axial view without contrast enhancement. Note the areas of increased signal bilaterally, known as periventricular hyperintensity (arrows).
  • 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”
  • AD combined with lacunes Data from Nun Study
  • Objectives
    • What is Vascular Dementia (VaD)?
    • Different types of VaD
    • Neuropsychiatric manifestations
    • Risk factors & common presentations
    • Diagnostic tests
    • Treatment options
  • 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
  • Frontal Sub-cortical symptoms
    • Area of the brain responsible for making us “human”
      • Complex social behaviour
      • Initiative
      • Forethought
      • Behavioural adaptability
    • 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
    • Disinhibition
    • Depression
    • AD doesn’t normally have above features until late in the course
  • 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)
  • 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!
    • 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
  •  
  • Objectives
    • What is Vascular Dementia (VaD)?
    • Different types of VaD
    • Neuropsychiatric manifestations
    • Risk factors & common presentations
    • Diagnostic tests
    • Treatment options
  • Risk factors
    • Hypertension
    • Diabetes
    • Hyperlipidemia
    • Age
    • Gender
    • Race
    • Hyper-homocysteinuria
  •  
  • Clinical examination
    • Clinician assessment
      • 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
    • On Examination
      • Looking for signs of neurological deficits, parkinsonism, asymmetry, gait changes
    • Laboratory Assessments
      • Bloodwork: C-reactive protein, lipids, homocysteine, glucose, HbA1C, insulin, clotting factors
  • Objectives
    • What is Vascular Dementia (VaD)?
    • Different types of VaD
    • Neuropsychiatric manifestations
    • Risk factors & common presentations
    • Diagnostic tests
    • Treatment options
    • MMSE not adequate because of lack sensitivity in VCI, as it isn’t a sensitive test for executive function, inattention, mood or personality changes
    • Montreal Cognitive Assessment (MoCA)
      • Increasingly popular
      • Designed for vascular dementia
      • http://mocatest.org/
    Cognitive Tests
    • www.mocatest.org
  • Objectives
    • What is Vascular Dementia (VaD)?
    • Different types of VaD
    • Neuropsychiatric manifestations
    • Risk factors & common presentations
    • Diagnostic tests
    • Treatment options
    • Enduring POA, health care proxy, will etc.
    • Distraction techniques
      • 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
    • 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)
    • “THE BEST NUMBER OF MEDICATIONS TO USE IS ZERO (or sometimes one)”
    • Jonathan T Stewart MD
    • WHEN IN DOUBT, GET RID OF MEDICATIONS!
  • Pharmacologic and medical treatment of VaD
    • Primary prevention:
      • Treatment of HTN, DM, hypercholestrolemia
    • Secondary prevention:
      • 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
    • STOP SMOKING!!!
    • Avoid orthostatic hypotension
    • Good control of congestive heart failure and obstructive sleep apnea
  •  
  • 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)
    • Atypical antipsychotics
  • 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
  •  
  • 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) 477–499
    • The frontal/subcortical dementias: Common dementing illnesses associated with prominent and disturbing behavioral changes. Geriatrics August 2006
    • www.mocatest.org