Diagnosing and managing vascular dementia

Vascular dementia (VaD) is common. Pure vascular disease may account for 5-20% of all cases of dementia, while mixed dementia, Alzheimer's disease (AD) with VaD, occurs at least as frequently. There is no specific treatment or cure for VaD, but its proximity to other conditions may make it amenable to interventions at various stages. The causes of VaD are multifactorial and involve neuronal networks needed for memory and cognition, executive function and behaviour. Hypertensive angiopathy is the major known causative factor for VaD. Recent research suggests that VaD and AD occupy ends of the same spectrum and share common risk factors. As VaD is closely related to cardiovascular disease, modifying cardiovascular risk factors may assist in its prevention. Hypertension in midlife increases the risk of all-cause dementia. Regular screening of high-risk individuals could help to detect dementia early on enabling appropriate preventive intervention. Medication for hypertension, diabetes, and hypercholesterolaemia is recommended. Behavioural treatments include enhancing and encouraging cognitive and physical activity, social engagement, smoking cessation and healthy diet, including alcohol reduction. Comorbid depression is common in older people with dementia and treating this can improve cognition. Typically, patients are in their late sixties or early seventies, and may present after a cerebrovascular event. The onset is usually more acute than that of AD. Typical signs and symptoms are gait disturbance, unsteadiness and falls, urinary symptoms not explained by urological disease, pseudobulbar palsy and personality and mood changes. Insight is preserved until late in the disease and seizures or other manifestations of cerebral ischaemic accidents are not infrequent. VaD is characterised by stepwise deterioration with periods of partial recovery that can last months between periods of deterioration and cognitive decline.