Vascular dementia

Vascular dementia is a general term describing problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain.

You can develop vascular dementia after a stroke blocks an artery in your brain, but strokes don't always cause vascular dementia. Whether a stroke affects your thinking and reasoning depends on your stroke's severity and location. Vascular dementia can also result from other conditions that damage blood vessels and reduce circulation, depriving your brain of vital oxygen and nutrients.

Factors that increase your risk of heart disease and stroke — including diabetes, high blood pressure, high cholesterol and smoking — also raise your vascular dementia risk. Controlling these factors may help lower your chances of developing vascular dementia.

Vascular dementia symptoms vary, depending on the part of your brain where blood flow is impaired. Symptoms often overlap with those of other types of dementia, especially Alzheimer's disease dementia. But unlike Alzheimer's disease, the most significant symptoms of vascular dementia tend to involve speed of thinking and problem-solving rather than memory loss.

Vascular dementia signs and symptoms include:

• Confusion
• Trouble paying attention and concentrating
• Reduced ability to organize thoughts or actions
• Decline in ability to analyze a situation, develop an effective plan and communicate that plan to others
• Slowed thinking
• Difficulty with organization
• Difficulty deciding what to do next
• Problems with memory
• Restlessness and agitation
• Unsteady gait
• Sudden or frequent urge to urinate or inability to control passing urine
• Depression or apathy

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 post-stroke dementia.

Sometimes a characteristic pattern of vascular dementia symptoms follows a series of strokes or ministrokes. Changes in your thought processes occur in noticeable steps downward from your previous level of function, unlike the gradual, steady decline that typically occurs in Alzheimer's disease dementia.

But vascular dementia can also develop very gradually, just like Alzheimer's disease dementia. What's more, vascular disease and Alzheimer's disease often occur together.

Studies show that many people with dementia and evidence of brain vascular disease also have Alzheimer's disease.

Vascular dementia results from conditions that damage your brain's blood vessels, reducing their ability to supply your brain with the amounts of nutrition and oxygen it needs to perform thought processes effectively.

Common conditions that may lead to vascular dementia include:

• Stroke (infarction) blocking a brain artery. Strokes that block a brain artery usually cause a range of symptoms that may include vascular dementia. But some strokes don't cause any noticeable symptoms. These silent strokes still increase dementia risk.

  With both silent and apparent strokes, the risk of vascular dementia increases with the number of strokes that occur over time. One type of vascular dementia involving many strokes is called multi-infarct dementia.

• Brain hemorrhage. Often caused by high blood pressure weakening a blood vessel leading to bleeding into the brain causing damage or from buildup of protein in small blood vessels occurring with aging weakening them over time (cerebral amyloid angiopathy)
• Narrowed or chronically damaged brain blood vessels. Conditions that narrow or inflict long-term damage on your brain blood vessels also can lead to vascular dementia. These conditions include the wear and tear associated with aging, high blood pressure, abnormal aging of blood vessels (atherosclerosis), diabetes

In general, the risk factors for vascular dementia are the same as those for heart disease and stroke. Risk factors for vascular dementia include:

• Increasing age. Your risk of vascular dementia rises as you grow older. The disorder is rare before age 65, and the risk rises substantially by your 90s.
• History of heart attacks, strokes or ministrokes. If you've had a heart attack, you may be at increased risk of having blood vessel problems in your brain. The brain damage that occurs with a stroke or a ministroke (transient ischemic attack) may increase your risk of developing dementia.
• Abnormal aging of blood vessels (atherosclerosis). This condition occurs when deposits of cholesterol and other substances (plaques) build up in your arteries and narrow your blood vessels. Atherosclerosis can increase your risk of vascular dementia by reducing the flow of blood that nourishes your brain.
• High cholesterol. Elevated levels of low-density lipoprotein (LDL), the "bad" cholesterol, are associated with an increased risk of vascular dementia.
• High blood pressure. When your blood pressure's too high, it puts extra stress on blood vessels everywhere in your body, including your brain. This increases the risk of vascular problems in the brain.
• Diabetes. High glucose levels damage blood vessels throughout your body. Damage in brain blood vessels can increase your risk of stroke and vascular dementia.
• Smoking. Smoking directly damages your blood vessels, increasing your risk of atherosclerosis and other circulatory diseases, including vascular dementia.
• Obesity. Being overweight is a well-known risk factor for vascular diseases in general, and therefore, presumably increases your risk of vascular dementia.
• Atrial fibrillation. In this abnormal heart rhythm, the upper chambers of your heart begin to beat rapidly and irregularly, out of coordination with your heart's lower chambers. Atrial fibrillation increases your risk of stroke because it causes blood clots to form in the heart that can break off and go to the brain blood vessels.

The health of your brain's blood vessels is closely linked to your overall heart health. Taking these steps to keep your heart healthy may also help reduce your risk of vascular dementia:

• Maintain a healthy blood pressure. Keeping your blood pressure in the normal range may help prevent both vascular dementia and Alzheimer's disease.
• Prevent or control diabetes. Avoiding the onset of type 2 diabetes, with diet and exercise, is another possible way to decrease your risk of dementia. If you already have diabetes, controlling your glucose levels may help protect your brain blood vessels from damage.
• Quit smoking. Smoking tobacco damages blood vessels everywhere in your body.
• Get physical exercise. Regular physical activity should be a key part of everyone's wellness plan. In addition to all of its other benefits, exercise may help you avoid vascular dementia.
• Keep your cholesterol in check. A healthy, low-fat diet and cholesterol-lowering medications if you need them may reduce your risk of strokes and heart attacks that could lead to vascular dementia, probably by reducing the amount of plaque deposits building up inside your brain's arteries.

Doctors can nearly always determine that you have dementia, but there's no specific test that confirms you have vascular dementia. Your doctor will make a judgment about whether vascular dementia is the most likely cause of your symptoms based on the information you provide, your medical history for stroke or disorders of the heart and blood vessels, and results of tests that may help clarify your diagnosis.

Lab tests

If your medical record doesn't include recent values for key indicators of the health of your heart and blood vessels, your doctor will test your:

• Blood pressure
• Cholesterol
• Blood sugar

He or she may also order tests to rule out other potential causes of memory loss and confusion, such as:

• Thyroid disorders
• Vitamin deficiencies

Neurological exam

Your doctor is likely to check your overall neurological health by testing your:

• Reflexes
• Muscle tone and strength, and how strength on one side of your body compares with the other side
• Ability to get up from a chair and walk across the room
• Sense of touch and sight
• Coordination
• Balance

Brain imaging

Images of your brain can pinpoint visible abnormalities caused by strokes, blood vessel diseases, tumors or trauma that may cause changes in thinking and reasoning. A brain-imaging study can help your doctor zero in on more-likely causes for your symptoms and rule out other causes.

Brain-imaging procedures your doctor may recommend to help diagnose vascular dementia include:

• Magnetic resonance imaging (MRI). An MRI uses radio waves and a strong magnetic field to produce detailed images of your brain. You lie on a narrow table that slides into a tube-shaped MRI machine, which makes loud banging noises while it produces images.

  MRIs are painless, but some people feel claustrophobic inside the machine and are disturbed by the noise. MRIs are generally the preferred imaging test because MRIs can provide even more detail than CT scans about strokes, ministrokes and blood vessel abnormalities and is the test of choice for evaluating vascular dementia.

• Computerized tomography (CT) scan. For a CT scan, you'll lie on a narrow table that slides into a small chamber. X-rays pass through your body from various angles, and a computer uses this information to create detailed cross-sectional images (slices) of your brain.

  A CT scan can provide information about your brain's structure; tell whether any regions show shrinkage; and detect evidence of a stroke, ministroke (transient ischemic attacks), a change in blood vessels or a tumor.

Neuropsychological tests

This type of exam assesses your ability to:

• Speak, write and understand language
• Work with numbers
• Learn and remember information
• Develop a plan of attack and solve a problem
• Respond effectively to hypothetical situations

Neuropsychological tests sometimes show characteristic results for people with different types of dementia. People with vascular dementia may have an exceptionally hard time analyzing a problem and developing an effective solution.

They may be less likely to have trouble learning new information and remembering than are people with dementia due to Alzheimer's disease unless their blood vessel problems affect specific brain regions important for memory. However, there's often a lot of overlap in exam results for people with vascular dementia and people who also have the brain changes of Alzheimer's disease.

Overlap between vascular and Alzheimer's dementia

While much focus is placed on distinguishing Alzheimer's dementia from vascular dementia, it turns out there is usually substantial overlap. Most people diagnosed with Alzheimer's dementia have a vascular component and similarly most people with vascular dementia have some degree of coexisting Alzheimer's changes in their brain.

Treatment often focuses on managing the health conditions and risk factors that contribute to vascular dementia.

Controlling conditions that affect the underlying health of your heart and blood vessels can sometimes slow the rate at which vascular dementia gets worse, and may also sometimes prevent further decline. Depending on your individual situation, your doctor may prescribe medications to:

• Lower your blood pressure
• Reduce your cholesterol level
• Prevent your blood from clotting and keep your arteries clear
• Help control your blood sugar if you have diabetes

Though these haven't been proved to alter the course of vascular dementia, your doctor will likely recommend that you:

• Participate in regular physical activity
• Eat healthy
• Try to maintain a normal weight
• Engage in social activities
• Challenge your brain with games, puzzles and new activities, such as an art class or listening to new music
• Limit how much alcohol you drink

People with any type of dementia and their caregivers — whether it's vascular dementia or Alzheimer's disease — experience a mixture of emotions, including confusion, frustration, anger, fear, uncertainty, grief and depression.

Caring for someone with dementia

• Seek out support. Many people with dementia and their families benefit from counseling or local support services. Contact your local Alzheimer's Association affiliate to connect with support groups, resources and referrals, home care agencies, residential care facilities, a telephone help line, and educational seminars.
• Plan for the future. While your loved one is in the earlier stages of the disease, talk with a lawyer about the types of legal documents you'll need in the future, such as power of attorney, health care proxy and an advanced directive.
• Give encouragement. Care partners can help a person cope with vascular dementia by being there to listen, reassuring the person that life can still be enjoyed, providing encouragement, and doing their best to help the person retain dignity and self-respect.
• Provide a calm environment. A calm and predictable environment can help reduce worry and agitation. Establish a daily routine that includes enjoyable activities well within the comfort zone of the person with vascular dementia.
• Do activities together. Instead of dwelling on what's to come, try to find activities you both like to do, such as a painting class or a long walk.
• Respect independence as often as is safe. It may be a long time before your loved one has to give up living alone or driving. The early stages of dementia can last years, and your loved one may still be capable of doing many things on his or her own. If you and your loved one can't agree on when it's time to stop certain activities, such as driving, ask your loved one's doctor for his or her advice.

Caring for the caregiver or care partner

Providing care for and supporting a person with dementia is physically and emotionally demanding. Feelings of anger and guilt, frustration and discouragement, worry and grief, and social isolation are common. But paying attention to your own needs and well-being is one of the most important things you can do for yourself and for the person in your care.

If you're a caregiver or care partner:

• Learn as much about the disease as you can. Ask your primary care doctor or neurologist about good sources of information. Your local librarian also can help you find good resources.
• Ask questions of doctors, social workers and others involved in the care of your loved one.
• Call on friends and family members for help when you need it.
• Take a break every day.
• Take care of your health by seeing your own doctors on schedule, eating healthy meals and getting exercise.
• Make time for friends, and consider joining a support group.

If you've had a stroke, your first conversations about your symptoms and recovery will likely take place in the hospital. If you're noticing milder symptoms, you may decide that you want to talk to your doctor about changes in your thought processes, or you may seek care at the urging of a family member who arranges your appointment and goes with you.

You may start by seeing your primary care doctor, but he or she is likely to refer you to a doctor who specializes in disorders of the brain and nervous system (neurologist).

Because appointments can be brief, and there's often a lot of ground to cover, it's a good idea to be well prepared for your appointment. Here's some information to help you get ready and know what to expect from your doctor.

What you can do

• Be aware of any pre-appointment restrictions. When you make your appointment, ask if you need to fast for blood tests or if you need to do anything else to prepare for diagnostic tests.
• Write down all of your symptoms. Your doctor will want to know details about what's causing your concern about your memory or mental function. Make notes about some of the most important examples of forgetfulness, poor judgment or other lapses you want to mention. Try to remember when you first started to suspect that something might be wrong. If you think your difficulties are getting worse, be ready to describe them.
• Take along a family member or friend, if possible. Corroboration from a relative or trusted friend can play a key role in confirming that your difficulties are apparent to others. Having someone along can also help you recall all the information provided during your appointment.
• Make a list of your other medical conditions. Your doctor will want to know if you're currently being treated for diabetes, high blood pressure, heart disease, past strokes or any other conditions.
• Make a list of all your medications, including over-the-counter drugs and vitamins or supplements.

Writing down a list of questions ahead of time can help you remember your biggest concerns and allow you to make the most of your appointment. If you're seeing your doctor regarding concerns about vascular dementia, some questions to ask include:

• Do you think I have memory problems?
• Do you think my symptoms are due to circulation problems in my brain?
• What tests do I need?
• If I have vascular dementia, will you or another doctor manage my ongoing care? Can you help me get a plan in place to work with all my doctors?
• What treatments are available?
• Is there anything I can do that might help slow the progression of dementia?
• Are there any clinical trials of experimental treatments I should consider?
• What should I expect to happen over the long term? What steps do I need to take to prepare?
• Will my symptoms affect how I manage my other health conditions?
• Do you have any brochures or other printed material I can take home with me? What websites and support resources do you recommend?

In addition to the questions you've prepared ahead of time, don't hesitate to ask your doctor to clarify anything you don't understand.

What to expect from your doctor

Your doctor is also likely to have questions for you. Being ready to respond may free up time to focus on any points you want to talk about in-depth. Your doctor may ask:

• What kinds of thinking problems and mental lapses are you having? When did you first notice them?
• Are they steadily getting worse, or are they sometimes better and sometimes worse? Have they suddenly gotten worse?
• Has anyone close to you expressed concern about your thinking and reasoning?
• Have you started having problems with any long-standing activities or hobbies?
• Do you feel any sadder or more anxious than usual?
• Have you gotten lost lately on a driving route or in a situation that's usually familiar to you?
• Have you noticed any changes in the way you react to people or events?
• Do you have any change in your energy level?
• Are you currently being treated for high blood pressure, high cholesterol, diabetes, heart disease or stroke? Have you been treated for any of these in the past?
• What medications, vitamins or supplements are you taking?
• Do you drink alcohol or smoke? How much?
• Have you noticed any trembling or trouble walking?
• Are you having any trouble remembering your medical appointments or when to take your medication?
• Have you had your hearing and vision tested recently?
• Did anyone else in your family ever have trouble with thinking or remembering things as they got older? Was anyone ever diagnosed with Alzheimer's disease or dementia?