Alzheimer's v Vascular Dementia Can you tell the difference?

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  • 1. Alzheimer’s v Vascular Dementia Can you tell the difference? Jonathan Waite Lings Bar Hospital Nottingham
  • 2. Alzheimer’s v Vascular
    • Plaques
    • Tangles
    • Insidious onset
    • Progressive deterioration
    • Infarction
    • Sudden onset
    • Stepwise deterioration
    • Focal signs and symptoms
    • Pathological emotionalism
  • 3. Hachinski Score
    • Abrupt onset 2
    • Stepwise deterioration 1
    • Fluctuating course 2
    • Nocturnal confusion 1
    • Personality preservation 1
    • Depression 1
    • Somatic complaints 1
    • Emotional
    • incontinence 1
    • Hypertension 1
    • Strokes 2
    • Vascular disease 1
    • Focal signs 2
    • Focal symptoms 2
    < = 4 Alzheimer’s Disease, > 7 Multi-Infarct Dementia
  • 4. Evidence for mixed disorders
    • Dementia in absence of cerebral infarction requires 8x greater tangle burden (Snowden et al 1997)
    • Only 13% patients clinically diagnosed as having VaD had pure VaD at PM (50% pure AD, 37% mixed) (Nolan et al 1998)
    • >40% of patients meeting vascular dementia criteria have AD pathology (Kalaria 2003)
    • Only 21% of Alzheimer cases have pure AD pathology (MRC-CFANS Ince 2004)
  • 5. Pathology in MRC-CFANS Non-demented Demented 5 / 35 27 / 29 26 / 21 43 / 15 Plaques 0 / 20 8 / 19 25 / 22 66 / 39 Tangles Severe Mod Mild None 5 3 1 0 CERAD
  • 6. MRC-CFANS - Vascular demented non-demented 33 / 46 64 / 75 31 / 37 76 / 81 Multiple pathologies Small vessel disease Infarcts Any
  • 7. But…
    • “ the lack of clear blue water between Alzheimer disease and vascular dementia is plainly acknowledged” British Journal of Psychiatry (2002) 180 97-98
  • 8. Unimodal v Bimodal Alzheimer Mixed Vascular
  • 9. Sir Martin Roth FRS 1917-
    • Roth (1955)
    • The natural history of metal disorder in old age
    • Blessed, Tomlinson & Roth (1968)
    • The association between quantitative measures of dementia and of senile change in the cerebral grey matter of elderly subjects
    • Roth & Wischik (1985)
    • Heterogeneity in senile dementia
  • 10. Sir Martin Roth FRS 1917-
    • Carney Roth & Garside (1955)
    • The diagnosis of depressive symptoms and the prediction of ECT response
  • 11. Endogenous v Reactive Endogenous Mixed Reactive
  • 12. Bob Kendell 1935-2002
    • The Role of Diagnosis in Psychiatry (Oxford: Blackwell 1975)
  • 13. Psychotic v Endogenous Depression
    • Roth
    • Bimodal distribution
    • Two separate disorders
    • Kendell
    • Unimodal distribution
    • Single disorder with distinctive psychopathology at extremes of continuum
  • 14. Alzheimer’s v Vascular Alzheimer Mixed Vascular
  • 15. Risk factors for Alzheimer’s Disease
    • Diabetes (Stewart 1998)
    • Midlife hypertension (Elias et al 1993)
    • Smoking (Ott et al 1998, Launer et al 1999)
    • Atrial fibrillation ( Stewart et al 1999)
    • Stroke (Kalaria & Skoog 2000)
    • Cholesterol (Notkola et al 1998, Kivipelto et al 2001)
  • 16. Risk factors for Vascular Dementia
    • Diabetes (Desmond et al 1993)
    • Midlife hypertension (Lindsay et al 1997 )
    • Smoking (Meyer et al 1988)
    • Atrial fibrillation ( Stewart et al 1999)
    • Stroke (Blessed et al 1968)
    • Cholesterol (Moroney et al 1999)
  • 17. Cholinesterase Inhibitors
    • Response to ChEI in vascular dementia
    • Galantamine (Erkinjuntti et al 2002)
    • Donepezil (Black et al 2003)
  • 18. Natural History
    • ? Recent studies
    • Christie (1985) – no significant differences between diagnostic groups
  • 19. Understanding Vascular Dementia
    • Hearts & Brains
    • Mind Your Head
    • www.alzheimers.org.uk
  • 20. Conclusions
    • Consider vascular risk factors in Alzheimer’s Disease
    • Consider Alzheimer’s Disease in patients with vascular disorders