Swank Center for Memory Care and Geriatric Consultation, ChristianaCare
Vascular dementia is caused by damage to brain cells deprived of blood flow and life-sustaining oxygen and nutrients due to reduced circulation or blockage of the brain’s blood vessels. The subsequent brain damage results in cognition and behavior changes. Learn how it differs from Alzheimer’s disease.
Mary’s* first visible stroke, was at age 73. Mary was a heavy smoker. Her high blood pressure was usually under control and she took medication to keep her cholesterol within normal range. Given her high stress job and the devoted care she was providing on a daily basis to her disabled father, she didn’t find much time to relax or to exercise.
Just after supper one evening she turned to her father to ask whether there was anything more she could bring him. She couldn’t get the words out, and she had trouble standing up because of weakness in her right leg. She and her father knew what was happening. They called an ambulance. As a result of their rapid recognition and response, the damage to Mary’s brain was limited.
Mary’s care providers recognized her multiple vascular risk factors and encouraged her to reduce stress, quit smoking, and control her blood pressure and cholesterol more consistently. They were concerned about her future when imaging studies showed Mary had sustained earlier strokes that had been clinically silent.
Six months later, her strength and her speech improved. Her thinking, though, seemed sluggish and her ability to follow directions, manage her checkbook, or remember conversations or events was still affected. Mary was no longer able to drive safely and she couldn’t continue to live independently. Her doctor diagnosed vascular dementia.
Like Mary, her father, at age 94, was no longer independent. He too had been a heavy smoker with the additional vascular risk factors of high blood pressure and high cholesterol. His brain imaging studies showed no large strokes but revealed a prominent whitish cloud typical of compromised small blood vessels. Mary’s father had slowed down considerably from his vigorous earlier years. He had trouble focusing and paying attention. His memory was no longer reliable for recent events, although reminders often helped him recall what he had forgotten. His control of urination was unreliable and he had fallen on several recent occasions as a result of his unstable gait. He was diagnosed with vascular dementia of a different variety, the type that occurs without large strokes but instead results from disruption of brain function related to widespread disease of the brain’s white matter** and microcirculation.
* To protect anonymity, the story of Mary and her father is a composite of symptoms from various patients.
** White matter refers to the nerve fibers that connect parts of the nervous system.
Vascular dementia is the end stage of vascular cognitive impairment (VCI), a spectrum of cognitive disorders ranging from mild vascular cognitive impairment to dementia. Some authorities say it is the second most common dementia in older adults.
Like dementia related to Alzheimer’s disease (AD), vascular dementia is diagnosed when cognitive decline robs a person of independence and it is not the consequence of other neurological or psychiatric disorders. Many older adults develop both AD and vascular disease, a combination that leads to worse cognitive decline and more frequent behavioral problems than those seen with vascular dementia or AD alone.
Unlike AD, VCI often begins with symptoms other than the loss of the ability to recall and reexperience specific episodes from one’s past. Researchers have noted that people with VCI often develop more noticeable difficulty with attention, information processing, and executive functioning (which are skills that enable people to plan, organize, remember things, prioritize, or pay attention to tasks) at the outset of the disease. Memory and language effects vary more. Changes in behavior including depression and apathy are common. Recognition of VCI is complicated by the fact that some standard dementia tests are less able to detect the impairment associated with VCI.
VCI and its end-stage of vascular dementia are now considered a group of diseases rather than a single disease. A major stroke is often followed by vascular cognitive impairment, as in Mary’s case. The smaller silent strokes, called lacunar infarcts, can lead to VCI in people who have not experienced larger strokes. But Mary’s father, with his “white matter disease,” is typical of the largest number of people with VCI. His damage is the result of thickening and narrowing (atherosclerosis) of arteries that feed the deep layers of white matter in the brain. Mary’s father’s condition used to be called “Binswanger’s disease” and is now considered a common type of VCI.
VCI can develop in other ways, too. In people who have experienced bleeding into the brain from an aneurysm or other cause, cognitive effects may remain. VCI can also be the result of some rare hereditary disorders such as CADASIL (a condition that causes stroke and other impairments), which stands for cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy.
Further Reading:
James Ellison, MD received his medical degree from UCSF in 1978 and trained in psychiatry at the Massachusetts General Hospital (1979-1982).
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