Vascular Dementia Final


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Vascular Dementia

Vascular Dementia Final

  1. 1. Tom Pitts Psiquiatría 16 de Mayo-2001
  2. 2. <ul><li>Dementia - A decline in a person's mental capacities and intellectual abilities that is great enough to affect the person's normal daily functioning. </li></ul><ul><li>Vascular dementia - A dementia syndrome likely to be the consequence of lesions of the brain, vascular in origin, irrespective of their ischemic, hemorrhagic or hypoxic nature. </li></ul>
  3. 3. <ul><li>Vascular dementia is more common in men than in women (possibly because men are more likely than women to suffer from strokes). </li></ul><ul><li>Vascular dementia becomes increasingly prevalent as people grow older. </li></ul><ul><li>The number of people affected by vascular dementia rises dramatically during and after the sixth decade. *65 on Step </li></ul><ul><li>Vascular dementia usually occurs at a younger age than AD. </li></ul><ul><li>Vascular dementia usually presents in an acute & stepwise fashion meaning a “step” is lost after each event (stroke/CVA) </li></ul>
  4. 4. <ul><li>A. The development of multiple cognitive deficits manifested by both: </li></ul><ul><ul><li>A1 - Memory impairment (impaired ability to learn new information or to recall previously learned information) </li></ul></ul><ul><ul><li>A2 - One or more of the following cognitive disturbances: </li></ul></ul><ul><ul><ul><li>(1) aphasia (language disturbance) </li></ul></ul></ul><ul><ul><ul><li>(2) apraxia (impaired ability to carry out motor activities despite intact motor function) </li></ul></ul></ul><ul><ul><ul><li>(3) agnosia (failure to recognize or identify objects despite intact sensory function) </li></ul></ul></ul><ul><ul><ul><li>(4) disturbance in executive functioning (i.e., planning, organizing, sequencing, abstracting) </li></ul></ul></ul><ul><li>B. The cognitive deficits in criteria A1 and A2 each cause significant impairment in social or occupational functioning and represent a significant decline from a previous level of functioning. </li></ul><ul><li>C. Focal neurological signs and symptoms (e.g., exaggeration of deep tendon reflexes, extensor plantar response, psuedobulbar palsy, gait abnormalities, weakness of an extremity) or laboratory evidence indicative of cerebrovascular disease (e.g., multiple infarctions involving cortex and underlying white matter) that are judged to be etiologically related to the disturbance. </li></ul><ul><li>D. The deficits do not occur exclusively during the course of a delirium. </li></ul>
  5. 5. <ul><li>Three other types, based on the predominant feature of the dementia can be diagnosed using DSM IV criteria. </li></ul><ul><ul><li>vascular dementia with delirium, </li></ul></ul><ul><ul><li>vascular dementia with delusions </li></ul></ul><ul><ul><li>vascular dementia with depressed mood . </li></ul></ul><ul><ul><li>If there are significant behavioral disturbances occurring as a result of the dementia, then that disturbance is specified. </li></ul></ul>
  6. 6. <ul><li>Six subtypes </li></ul><ul><ul><li>(1) multi-infarct dementia, </li></ul></ul><ul><ul><li>(2) strategic single infarct dementia, </li></ul></ul><ul><ul><li>(3) small-vessel disease with dementia, </li></ul></ul><ul><ul><li>(4) hypoperfusion dementia, </li></ul></ul><ul><ul><li>(5) hemorrhagic dementia </li></ul></ul><ul><ul><li>(6) other vascular dementia </li></ul></ul>
  7. 7. <ul><li>(i) stroke characteristics--i.e., lacunar infarcts, localization in the left hemisphere and/or in strategic regions. </li></ul><ul><li>(ii) white matter changes frequently seen in stroke patients, especially in those who have lacunes or deep hemorrhages, represent a strong predictor for risk of dementia. </li></ul><ul><li>(iii) associated Alzheimer pathology--Alzheimer and vascular lesions are frequently associated. Finally, it should also be considered the role of the summation of various lesion types, since many cases of dementia occurring in stroke patients are multifactorial. </li></ul><ul><li>(iv) cannot diagnose when concomitant delirium is present. </li></ul>
  8. 8. <ul><li>Vascular dementia symptoms vary, depending on the part of your brain where blood flow is impaired. </li></ul><ul><li>Symptoms often overlap with those of other types of dementia, especially Alzheimer's disease. </li></ul><ul><li>Vascular dementia symptoms may be most clear-cut when they occur suddenly following a stroke. When changes in your thinking and reasoning seem clearly linked to a stroke, this condition is sometimes called &quot;post-stroke dementia.&quot; </li></ul>
  9. 9. <ul><li>Cognitive </li></ul><ul><ul><li>Confusion, disorientation </li></ul></ul><ul><ul><li>Trouble paying attention and concentrating </li></ul></ul><ul><ul><li>Reduced ability to organize thoughts or actions </li></ul></ul><ul><ul><li>Decline in ability to analyze a situation, develop an effective plan, and communicate plan to others </li></ul></ul><ul><ul><li>Difficulty deciding what to do next </li></ul></ul><ul><ul><li>Problems with memory </li></ul></ul><ul><li>Emotional </li></ul><ul><ul><li>Depression </li></ul></ul><ul><li>Conduct </li></ul><ul><ul><li>Restlessness </li></ul></ul><ul><ul><li>Agitation </li></ul></ul><ul><li>Coordination </li></ul><ul><ul><li>Unsteady gait </li></ul></ul><ul><ul><li>*Wandering at night w/ or w/o elopement </li></ul></ul><ul><li>Physical </li></ul><ul><ul><li>Sudden or frequent urge to urinate, or inability to control passing urine (can be difficult to differentiate in an elderly male with concomitant prostate pathology and can present with a significant overlay) </li></ul></ul>
  10. 10. <ul><li>Initial Labs </li></ul><ul><ul><li>CBC </li></ul></ul><ul><ul><li>erythrocyte sedimentation rate </li></ul></ul><ul><ul><li>blood glucose level </li></ul></ul><ul><ul><li>renal and LFTs </li></ul></ul><ul><ul><li>syphilis serology </li></ul></ul><ul><ul><li>vitamin B12 </li></ul></ul><ul><ul><li>folate </li></ul></ul><ul><ul><li>thyroid function </li></ul></ul><ul><ul><li>CT or MRI brain </li></ul></ul><ul><ul><li>ECG </li></ul></ul><ul><li>Other Tests to Consider </li></ul><ul><ul><li>lupus anticoagulant, antiphospholipid, and antinuclear testing </li></ul></ul><ul><ul><li>neuropsychologic testing </li></ul></ul><ul><ul><li>carotid duplex </li></ul></ul><ul><li>Emerging Tests </li></ul><ul><ul><li>echocardiogram </li></ul></ul>
  11. 11. <ul><li>Vascular dementia symptoms sometimes follows a series of strokes or mini strokes. In this characteristic pattern, changes in the patient’s thought processes occur in noticeable &quot;steps&quot; downward from your previous level of function, unlike the gradual, steady decline that typically occurs in Alzheimer's disease. </li></ul><ul><li>Take notice however that vascular dementia can also develop very gradually, just like Alzheimer's disease. </li></ul>
  12. 12. <ul><li>Mixed dementia is diagnosed when patients have evidence of Alzheimer’s and cerebrovascular disease, either clinically or based on neuroimaging evidence of ischemic lesions. </li></ul><ul><li>Vascular dementia and Alzheimer's disease often coexist, especially in older patients with dementia. </li></ul>
  13. 13. <ul><li>Increasing age - The disorder is rare before age 65, and risk rises substantially in the eighth and ninth decade. </li></ul><ul><li>History of heart attack, strokes or mini strokes - The brain damage that occurs with a stroke or a mini stroke (transient ischemic attack) may increase your risk of developing dementia. </li></ul><ul><li>Atherosclerosis - Atherosclerosis can increase your risk of vascular dementia, and possibly your risk of Alzheimer's disease by reducing the flow of blood that nourishes the brain. </li></ul><ul><li>High cholesterol - Elevated levels of low-density lipoprotein (LDL) are associated with an increased risk of vascular dementia, and possibly with a higher risk of Alzheimer's disease. </li></ul><ul><li>High blood pressure - Extra stress on blood vessels everywhere in the body, including the brain. This increases the risk of vascular problems in the brain. </li></ul><ul><li>Diabetes. High glucose levels damage blood vessels throughout the body. </li></ul><ul><li>Smoking – Increased risk of atherosclerosis and other circulatory diseases, including vascular dementia. </li></ul><ul><li>Atrial fibrillation - Atrial fibrillation increases risk of stroke by leading to poor blood flow to the brain and elsewhere in the body. </li></ul>
  14. 14. <ul><li>The treatments for vascular dementia focus on attempts to slow or halt the progression of the disorder and alleviate some of the symptoms. The disorder cannot be cured or reversed. </li></ul><ul><li>The most common way to treat vascular dementia is to try to prevent further strokes, usually by eliminating/controlling risk factors. </li></ul><ul><li>Treatments include diet and drug treatment for hypertension (high blood pressure), aspirin therapy, smoking cessation, avoidance of heavy alcohol use, and stress reduction. </li></ul><ul><li>Some drugs that are used to treat mild AD are being studied for their effectiveness in treating vascular dementia. </li></ul>
  15. 15. <ul><li>The Food and Drug Administration (FDA) has not approved any drugs specifically to treat changes in judgment, planning, memory and other thought processes caused by vascular dementia. certain FDA approved Alzheimer's medications may also help people with vascular dementia to the same modest extent they help those with Alzheimer's. </li></ul><ul><li>Cholinesterase inhibitors — including donepezil (Aricept), galantamine (Razadyne) and rivastigmine (Exelon) </li></ul><ul><ul><li>Prevents Ach break down and thus increases amount of available Ach which is involved in memory and judgment. </li></ul></ul><ul><ul><li>Side effects can include nausea, vomiting, muscle cramps and diarrhea. </li></ul></ul><ul><li>Memantine (Namenda) </li></ul><ul><ul><li>Antagonizes the NMDA glutamate receptors which are important for information processing, storage and retrieval. </li></ul></ul><ul><ul><li>Side effects can include headache, constipation, confusion and dizziness. </li></ul></ul>
  16. 16. <ul><li>A 76-year-old white woman is brought to the physician by her children because she is becoming more forgetful. She used to pay her bills independently and enjoyed cooking but has recently received overdue notices from utility companies and found it difficult to prepare a balanced meal. She has lost 3.5 kg in the past 3 months, and left the water running in her bathtub and flooded the bathroom. When her children express their concerns, she becomes irritable and resists their help. Her house has become more cluttered and unkempt. On a past visit to her physician, she had normal laboratory tests for metabolic, hematologic, and thyroid function. The current evaluation reveals no depressive symptoms and 2/15 on the Geriatric Depression Scale short-form. Her MMSE score is 20/30. </li></ul>
  17. 17. <ul><li>Vascular Dementia </li></ul><ul><li>Alzheimer’s Dementia </li></ul><ul><li>Mixed Disorder </li></ul><ul><li>Genetic Disorder </li></ul>
  18. 18. <ul><li>A 42-year-old school teacher presents with difficulty managing her classroom. She has become increasingly irritable with students and fails to complete assigned tasks on time. Her sister and husband report that she has become restless, pays less attention to her appearance and social obligations, and at times is anxious and upset. She has stumbled unexpectedly. On examination, her speech is somewhat uneven and she is inappropriately flippant. Subtracting serial 7s from 100, while seated with her eyes closed, brings out random &quot;piano-playing&quot; movements of the digits along with other movements of the limbs, torso, and face. Subtraction errors occur with this task. She is unable to keep her tongue fully protruded for 10 seconds. Finger tapping is slower than the examiner's, and tapping tempo is uneven. Tandem walking is impaired. </li></ul>
  19. 19. <ul><li>Vascular Dementia </li></ul><ul><li>Alzheimer’s Dementia </li></ul><ul><li>Mixed Disorder </li></ul><ul><li>Genetic Disorder </li></ul>
  20. 20. <ul><li>A 65-year-old man presents with difficulty in decision making and planning, which is of abrupt onset and occurs 3 months after a stroke. He has strong vascular risk factors, including smoking. Over time, there has been a fluctuating stepwise reduction in cognitive function. There is a history of nocturnal confusion and incontinence. On examination there is evidence of focal neurologic deficit with pseudobulbar palsy and extrapyramidal signs. Neuro-imaging indicates a probable vascular etiology with white matter changes and infarction. </li></ul>
  21. 21. <ul><li>Vascular Dementia </li></ul><ul><li>Alzheimer’s Dementia </li></ul><ul><li>Mixed Disorder </li></ul><ul><li>Genetic Disorder </li></ul>
  22. 22. <ul><li>A 76 y/o M patient with known Alzheimer’s disease presents to the ER with an acute mental status change following what his wife describes as “an episode of staring into space.” which she reports to have happened three times over the last year .The pt’s informant goes on to tell you that although her husband has suffered from Alzheimer’s dementia it seems to get worse or has an accompanying loss a function after these “starring episodes.” the pt is a 1 ppd smoker for 32 years. Social drinker. No illicit drug use. Vitals remarkable for BP of 179/105. pt has new onset unilateral loss of R. arm function, and although he had dementia previously he was always able to talk even if nonsensically. Today the pt looks at you intently when asked a question but cannot respond or makes incoherent sounds. </li></ul>
  23. 23. <ul><li>Vascular Dementia </li></ul><ul><li>Alzheimer’s Dementia </li></ul><ul><li>Mixed Disorder </li></ul><ul><li>Genetic Disorder </li></ul>
  24. 25. <ul><li>Mayo Clinic, “Vascular Dementia a guide” Accessed online may -9-2011, </li></ul><ul><li>American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC. </li></ul><ul><li>Cerebrovascular Mechanisms and Clinical Management (Current Clinical Neurology), Robert H. Paul , 2006, NY publishing, </li></ul><ul><li>Vascular Dementia and Alzheimer's Disease: Is There a Difference? </li></ul><ul><li>William C. Groves, M.D., Jason Brandt, Ph.D., Martin Steinberg, M.D., Andrew Warren, M.D., Adam Rosenblatt, M.D., Alva Baker, M.D. and Constantine G. Lyketsos, M.D., M.H.S. Received May 3, 1999; revised November 22, 1999; accepted December, Accessed May 10, 2011 </li></ul>