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geri:dementia:vascular [September 2018]
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 +====== Vascular Dementia ======
 +{{INLINETOC}}
 +===== Primer =====
 +**Vascular dementia** is a neurodegenerative disorder that occurs due to cerebrovascular disease and hypoperfusion. This can range from large vessel stroke to microvascular disease. The symptoms and presentation can be heterogenous,​ depending on the extent of vascular lesions and the anatomical location. Lesions can be limited to a single site, multifocal, or diffusely distributed.
  
 +== Prevalence ==
 +The prevalence for vascular dementia ranges from 0.2% in the 65-70 years age group to 16% in 80 years and older. Within 3 months post-stroke,​ 20%-30% of individuals are diagnosed with dementia. Prevalence is also higher in males than in females.
 +
 +== Symptoms ==
 +Patients with vascular dementia often have multiple infarctions,​ and have an acute stepwise or fluctuating decline in cognition. There can be intervening periods of stability and even improvement in some cases.
 +
 +===== Diagnostic Criteria =====
 +<WRAP group>
 +<WRAP half column>
 +== Criterion A ==
 +The criteria are met for [[cl:​2-major-neurocog-disorder|major]] or [[cl:​3-mild-neurocog-disorder|mild neurocognitive disorder]].
 +
 +== Criterion B ==
 +The clinical features are consistent with a vascular etiology, as suggested by either of the following:
 +  - Onset of the cognitive deficits is temporally related to one or more cerebrovascular events.
 +  - Evidence for decline is prominent in complex attention (including processing speed) and frontal-executive function.
 +
 +== Criterion C ==
 +There is evidence of the presence of cerebrovascular disease from history, physical examination,​ and/or neuroimaging considered sufficient to account for the neurocognitive deficits.
 +
 +== Criterion D ==
 +The symptoms are not better explained by another brain disease or systemic disorder.
 +
 +</​WRAP>​
 +<WRAP half column>
 +== Probable vs. Possible ==
 +**Probable** vascular neurocognitive disorder is diagnosed if one of the following is present; otherwise **possible** vascular neurocognitive disorder should be diagnosed:
 +
 +  - Clinical criteria are supported by neuroimaging evidence of significant parenchymal injury attributed to cerebrovascular disease (neuroimaging-supported)
 +  - The neurocognitive syndrome is temporally related to one or more documented cerebrovascular events
 +  - Both clinical and genetic (e.g. - cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy) evidence of cerebrovascular disease is present.
 +
 +**Possible** vascular neurocognitive disorder is diagnosed if the clinical criteria are met but neuroimaging is not available and the temporal relationship of the neurocognitive syndrome with one or more cerebrovascular events is not established.
 +
 +== Specifiers ==
 +<​accordion collapsed="​true">​
 +<panel icon="​fa fa-search-plus"​ size="​xs"​ title="​Specifiers">​
 +**Specify if:**
 +  * Probable major vascular neurocognitive disorder, with behavioral disturbance
 +  * Probable major vascular neurocognitive disorder, without behavioral disturbance
 +  * Possible major vascular neurocognitive disorder, with behavioral disturbance
 +  * Possible major vascular neurocognitive disorder, without behavioral disturbance
 +</​panel>​
 +</​accordion>​
 +</​WRAP>​
 +</​WRAP>​
 +===== Pathophysiology =====
 +
 +
 +===== Investigations =====
 +<WRAP group>
 +<WRAP half column>
 +In order to diagnose probable vascular dementia, there must be abnormalities on found on neuroimaging. However, if the neurocognitive impairment is temporally associated with one or more well-documented strokes, a probable diagnosis can be made in the absence of neuroimaging. For mild vascular dementia, history of a single stroke or extensive white matter disease is generally sufficient. For major vascular dementia, two or more strokes, a strategically placed stroke, or a combination of white matter disease and one or more lacunar is necessary.
 +</​WRAP>​
 +<WRAP half column>
 +Neuroimaging evidence (either [[neurology:​investigations:​neuroimaging:​mri|]] or [[neurology:​investigations:​neuroimaging:​ct|]]) of cerebrovascular disease should show: 
 +  * One or more large vessel infarcts or hemorrhages,​ or
 +  * A single infarct or hemorrhage (e.g., in angular gyrus, thalamus, basal forebrain), or
 +  * Two or more lacunar infarcts outside the brain stem, or
 +  * Extensive and confluent white matter lesions (also known as small vessel disease or subcortical ischemic changes)
 +
 +</​WRAP>​
 +</​WRAP>​
 +
 +
 +
 +===== Treatment =====
 +  * Acetylcholinesterase inhibitors ([[meds:​dementia:​donepezil|donepezil]],​ [[meds:​dementia:​rivastigmine|rivastigmine]],​ and [[meds:​dementia:​galantamine|galantamine]]) as a class are modestly efficacious for patients with mixed AD and vascular dementia pathology, and a trial of these medications is recommended for most patients diagnosed with AD.[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC3980908/​|Herrmann,​ N., Lanctôt, K. L., & Hogan, D. B. (2013). Pharmacological recommendations for the symptomatic treatment of dementia: the Canadian Consensus Conference on the Diagnosis and Treatment of Dementia 2012. Alzheimer'​s research & therapy, 5(1), S5.]])]
 +  * However, in //​isolated//​ vascular dementia, there is insufficient and inconsistent evidence support on whether acetylcholinesterase inhibitors are effective.[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC3980908/​|Herrmann,​ N., Lanctôt, K. L., & Hogan, D. B. (2013). Pharmacological recommendations for the symptomatic treatment of dementia: the Canadian Consensus Conference on the Diagnosis and Treatment of Dementia 2012. Alzheimer'​s research & therapy, 5(1), S5.]])]
 +===== Differential Diagnosis =====
 +===== Resources =====