Vascular Dementia

Vascular dementia is a common condition caused by reduced blood flow to the brain, leading to changes in memory, thinking, and behavior that can significantly impact daily life.

Table of contents

• What Is Vascular Dementia?
• What Causes Vascular Dementia?
• Signs and Symptoms
• How Is Vascular Dementia Diagnosed?
• Treatment and Management
• Outlook and Progression
• Prevention and Risk Factors

What Is Vascular Dementia?

Vascular dementia refers to changes in memory, thinking, and behavior that result from conditions affecting the blood vessels in the brain^[2]. When there is decreased blood flow to areas of the brain, brain tissue becomes damaged because it does not receive enough oxygen and nutrients^[6]. This damage can lead to problems with daily activities and thinking skills.

Vascular dementia is the second most common type of dementia after Alzheimer’s disease^[7]. It is estimated to affect around 180,000 people in the UK^[5], and about 1 to 4 out of 100 individuals aged 65 years will develop it, with the prevalence increasing to 14–16 out of 100 individuals over 80 years old^[12]. Vascular dementia is one of the most common types of dementia in people after age 65 in North America and Europe^[6].

Some experts prefer the term vascular cognitive impairment (VCI) because it better describes the full range of thinking changes caused by problems with blood flow, from mild to severe^[3]. The term “vascular cognitive impairment” indicates milder symptoms that don’t affect daily living, while “vascular dementia” describes more significant symptoms that do affect daily life^[1].

Vascular dementia can occur alone or alongside other types of dementia, particularly Alzheimer’s disease. When someone has more than one cause of dementia, providers call it mixed dementia^[6]. In fact, about 5% to 10% of people with dementia have only vascular dementia, but it often happens along with Alzheimer’s disease^[6].

What Causes Vascular Dementia?

Vascular dementia is caused by different conditions that interrupt the flow of blood and oxygen supply to the brain and damage blood vessels in the brain^[2]. Inadequate blood flow can damage and eventually kill cells anywhere in the body, but the brain is especially vulnerable^[3].

The condition can develop in several ways. Changes in thinking skills sometimes occur suddenly after a stroke, which blocks major blood vessels in the brain^[3]. A stroke occurs when a blood clot blocks an artery or a blood vessel bursts and causes bleeding inside the brain, cutting off the oxygen and nutrients brain cells need^[1]. However, not every stroke leads to vascular cognitive impairment^[1]. A person’s risk for dementia after stroke depends on the size and number of strokes and the brain regions affected^[7].

Thinking difficulties may also begin as mild changes that gradually worsen as a result of multiple minor strokes or another condition that affects smaller blood vessels, leading to widespread damage^[3]. People with vascular dementia almost always have abnormalities in the brain that can be seen on MRI scans. These abnormalities can include evidence of prior strokes, which are often small and sometimes without noticeable symptoms^[2]. Other abnormalities commonly found include diseased small blood vessels and changes in “white matter” — the connecting “wires” of the brain that are critical for relaying messages between brain regions^[2].

Vascular dementia can happen as a result of narrowing and blockage of the small blood vessels inside the brain, a single stroke where the blood supply to part of the brain is suddenly cut off, or lots of “mini strokes” (also called transient ischaemic attacks, or TIAs) that cause tiny but widespread damage to the brain^[5].

Several underlying conditions and risk factors increase the chance of developing vascular dementia. These problems are often linked to conditions such as high blood pressure and diabetes, and lifestyle factors such as smoking and being overweight^[5]. Specific risk factors include high blood pressure, problems with the heartbeat’s rhythm, diabetes, high cholesterol, obesity, smoking, physical inactivity, poor diet, hardening of the arteries (atherosclerosis), sleep apnea, and atrial fibrillation^[7][22].

Signs and Symptoms

Vascular dementia can start suddenly or begin slowly over time^[5]. Symptoms can appear suddenly and may progress over time, with possible short periods of improvement^[2]. When symptoms develop, they can vary widely depending on which parts of the brain are affected and how severe the damage is^[6].

Common symptoms include slowness of thought, difficulty with planning and understanding, and problems with concentration^[5]. People with vascular dementia may experience changes to their mood, personality, or behavior, feeling disoriented and confused^[5]. Difficulty walking and keeping balance is also common^[5].

Memory loss may occur, although problems with thinking, walking, and performing everyday activities are often the most prominent symptoms^[17]. Many people with vascular dementia also suffer from depression, which can result in less motivation to perform their usual activities or a lack of interest in the world around them^[17].

Additional symptoms may include bowel or bladder control problems, confusion that may get worse at night, difficulty understanding or using words, mood changes like irritability, problems with reasoning, organizing and planning, sleeping issues, tremors or reduced fine motor control, trouble concentrating, following instructions and completing tasks, uncontrolled episodes of laughing or crying, and walking and balance problems^[6].

Some people may experience difficulty performing tasks that used to be easy, such as paying bills, trouble following instructions or learning new information and routines, forgetting current or past events, misplacing items, getting lost on familiar routes, problems with language such as finding the right word or using the wrong word, changes in sleep patterns, difficulty reading and writing, loss of interest in things or people, poor judgment and loss of ability to perceive danger, and hallucinations or delusions^[7].

People with vascular dementia may also exhibit extreme anxiety about daily life, which may be shown by asking questions and repeating information about once familiar events and people, preparing for appointments or day care well ahead of time, and using notes and reminders endlessly^[17]. Apathy or a lack of initiative about tasks that used to be routine may occur, as activities now feel overwhelming^[17]. Frequent agitation may occur as people become less able to interpret their environment and control or express their feelings^[17].

Many people with vascular dementia also have symptoms of Alzheimer’s disease, such as problems with memory and language^[5]. These problems can make daily activities increasingly difficult, and someone with the condition may eventually be unable to look after themselves^[5].

How Is Vascular Dementia Diagnosed?

There is no single test for vascular dementia^[5]. Experts nearly always can determine dementia in people with dementia symptoms, although certain test results can help with a diagnosis^[11]. A diagnosis may be made based on the information provided, including any history of stroke or heart and blood vessel issues^[11].

If you think you have early symptoms of dementia, especially if you are over 65 years of age, it is important to see a doctor^[5]. If it is found at an early stage, treatment may be able to stop vascular dementia getting worse, or at least slow it down^[5].

The tests needed to make a diagnosis include an assessment of symptoms — for example, whether these are typical symptoms of vascular dementia^[5]. A full medical history is taken, including asking about a history of conditions related to vascular dementia, such as strokes or high blood pressure^[5]. An assessment of mental abilities is conducted, which will usually involve several tasks and questions^[5].

A brain scan, such as an MRI scan or CT scan, is performed to look for any changes that have happened in the brain^[5]. Images of the brain can pinpoint changes caused by strokes, blood vessel diseases, tumors, or trauma that may affect thinking and reasoning^[11]. MRI is generally the preferred imaging test to diagnose vascular cognitive impairment, as MRI results can provide more detail^[11].

Laboratory tests provide key indicators of the health of the heart and blood vessels. Tests can measure cholesterol levels and blood sugar levels^[11]. Other tests may check for potential causes of dementia symptoms and rule out others, such as checking thyroid function, compounds in the blood such as calcium and electrolytes, vitamin levels such as vitamin D or vitamin B12 (deficiencies in these vitamins could cause vascular cognitive impairment symptoms), and signs of other conditions^[11].

Neurological health can be determined by testing reflexes, muscle tone and strength, ability to get up from a chair and walk across the room, sense of touch and sight, coordination, and balance^[11].

Treatment and Management

There is currently no cure for vascular dementia and no way to reverse any loss of brain cells that happened before the condition was diagnosed^[5]. There are no effective pharmacological compounds approved for treatment of vascular dementia in any jurisdiction worldwide^[12]. However, treatment can sometimes help slow down vascular dementia^[5].

The main aim of treatment for vascular dementia is to treat the underlying cause to help stop the condition getting worse^[10]. Treatment aims to tackle the underlying cause, which may reduce the speed at which brain cells are lost^[5]. The mainstay of management is the prevention of new strokes, which includes administering antiplatelet drugs and controlling major vascular risk factors^[16].

This will often involve eating a healthy, balanced diet, losing weight if you are overweight, stopping smoking, getting fit, and cutting down on alcohol^[5]. Medicines may be taken, such as those used to treat high blood pressure, lower cholesterol, or prevent blood clots^[5]. Drug treatment is primarily used to prevent further worsening of vascular dementia by treating underlying diseases such as hypertension, hyperlipidemia, and diabetes mellitus^[16].

Controlling vascular risk factors is an effective way to lower someone’s risk of worsening dementia. This can be done by encouraging exercise, abstaining from smoking, drinking alcohol in moderation, and possibly changing diet to reduce salts and saturated fats^[17]. It is also important that people with vascular dementia have their blood pressure checked and their blood fat levels measured at least once a year^[17]. Some risk factors for stroke, such as high blood pressure, heart disease, diabetes, and high cholesterol, can be controlled with drugs^[17].

Other treatments, including physiotherapy, occupational therapy, dementia activities (such as memory cafes), and psychological therapies, can help reduce the impact of any existing problems^[5]. Sometimes medication may be used to improve mood if a person is feeling very down or depressed^[14]. Medication can also help with some of the problems seen in advanced vascular dementia, although there are risks in taking these drugs, so it is important to talk through all the advantages and disadvantages with family and a doctor before deciding to try them^[14].

Rehabilitation therapy can be helpful. Memory and stroke services often have a team of experts that can help with various dementia problems^[14]. If dementia is causing physical problems, such as falls, a person may be able to work with a physiotherapist or occupational therapist^[14]. A speech and language therapist may be able to help with any communication problems^[14]. An occupational therapist can work with a person to make sure that they can be as independent as possible, particularly in their home environment^[14].

Some therapies, including cognitive stimulation therapy, cognitive rehabilitation, and occupational therapy, can help people with mild to moderate dementia^[3]. Some people find group reminiscence work helpful^[3]. People should be offered some support to stay independent and develop their memory and concentration^[14].

Outlook and Progression

There are no clear stages of vascular dementia. It affects each person differently and progresses in a variety of ways^[6]. Vascular dementia tends to get worse over time, although it is sometimes possible to slow it down^[5].

Most often, symptoms get worse over many years. However, they may be most obvious and sudden after a major stroke^[6]. Vascular dementia will usually get worse over time. This can happen in sudden steps, with periods in between where the symptoms do not change much, but it is difficult to predict when this will happen^[5]. There may even be short periods when symptoms improve, but if more strokes occur, symptoms will worsen^[6].

As dementia progresses, more troubling behaviors such as agitation, aggression, wandering, sleep disorders, and inappropriate sexual behavior are observed^[16]. These problems can make daily activities increasingly difficult, and someone with the condition may eventually be unable to look after themselves^[5].

Home-based help will usually be needed, and some people will eventually need care in a nursing home^[5]. The decision for placement in institutions is usually made when problem behaviors become unmanageable, when more assistance is necessary in performing activities of daily living, when caring duties exceed the capacity of the caregiver, or when a breakdown in the family caregiver’s health occurs^[16].

Although treatment can help, vascular dementia can significantly shorten life expectancy. However, this is highly variable, and many people live for several years with the condition, or die from some other cause^[5].

Prevention and Risk Factors

By controlling or managing risk factors, you may lower your chance of developing cognitive impairment and dementia^[7]. Tackling problems linked to underlying conditions such as high blood pressure and diabetes, and lifestyle factors such as smoking and being overweight, might reduce your risk of vascular dementia in later life^[5].

High blood pressure, problems with the heartbeat’s rhythm, diabetes, and high cholesterol can increase a person’s risk of vascular dementia^[7]. Other risk factors include hardening of the arteries (atherosclerosis), sleep apnea, obesity, smoking, atrial fibrillation, physical inactivity, and poor diet^[22].

Research has shown a strong link between cardiovascular disease, involving the heart and blood vessels, and cerebrovascular disease, involving the brain, and subsequent cognitive impairment and dementia^[2]. Researchers are investigating whether the methods used to prevent and treat cerebrovascular disease and heart disease could also help prevent dementia^[2].

If vascular risk factors are not attended to properly, recurring strokes and worsening dementia symptoms may occur^[17]. While there is no current treatment to change the effects of vascular dementia, preventing risk for additional vascular damage, particularly stroke, can be an effective way to lower someone’s risk of worsening dementia^[17].

If you or a loved one has been diagnosed with dementia, remember that you are not alone. Health services and social services, as well as voluntary organizations, can provide advice and support^[5].