Subcortical Vascular Dementia - Case Presentation

Vascular Dementia

Diagnostic Criteria

Treatment of Vascular Dementia

Back to Mr. R...

Placed on Depakote (valproate) , Ativan (lorazepam) and Aricept (donezepil) as well as continued management of hypertension.

On the 45th day of Mr. R's admission, he was noted by the attending physician to be much calmer and cooperative to the nursive staff. The pt was re-evaluated and was found to have significantly improved cognitive ability and was A&O x 3. He greeted the interviewer with a handshake and was cooperative during the full mental status exam. When asked about his past behavior, he was aware of his inappropriate behavior and was apologetic. After further psychiatric followup, the patient was discharged home.

Subcortical Vascular Dementia

Darren Kwong, OMS-III

10.26.2006

Case Presentation

Mr. R is a 66 y/o male who presented with bizarre behavior s/p a mechanical fall at home. At the time of interview, he was on his 25th day of hospitalization. Initial history and MSE incomplete due to pt uncooperation. Upon questioning and history taking, pt simply repeated “Doc, Doc, I have to get out of here! I gotta go, I gotta go!” Pt was observed to be demented and confused, A&O x 1, however no auditory or visual hallucinations were elicited. Over the course of the next two weeks, Pt was observed by nursing staff to continue to be uncooperative and Pt was required to be put in restraints two times. Limited history was obtained from pt’s wife though she stated that he had a h/o multiple mini-cerebral infarcts. She also noted that two weeks prior to hospitalization, she noticed personality changes, increased irritability and inappropriate behavior.

Differential Dx?

Laboratory results show a mild anemia (H&H of 11 and 33.3) and increased free T4.

Radiology imaging showed no mass lesion, hemorrhage or territorial infarction. Chronic microangiopathic changes in the brain were found on both CT and MRI studies. Ischemic demyelination was also noted on MRI.

• Drug induced (Cocaine, LSD, amphetamines)
• Substance Withdrawl (Delirium tremens)
• Alzheimer’s Dementia
• Vascular dementia
• Brain mass or malignancy
• Infection - Encephalitis, Meningitis
• Concussion/ Trauma

• second most common form of dementia after Alzheimer disease

severity of stroke

• cerebral microinfarcts accounted for ~33% of the population at risk for dementia

age

• estmated prevalence for VaD vary between 1.2 to 4.2% of indivduals > 65 y/o

atrial fibrillation

presence of white matter disease

Risk Factors

cortical atropy on imaging

hypertension

obesity

"cognitive impairment that is caused by or associated with vascular factors"

-National Institute of Neurological Disorders

elevated homocystein or HDL leves

diabetes mellitus

Large Artery Infarctions

Small Artery Infarctions or Lacunes

Chronic Subcortical Ischemia

Usually coritcal

Sometimes subcoritcal

exclusively subcortical

in the small penetrating arteries

affects the basal ganglia, caudate, thalamus, internal capsule, cerebellum and brainstem

small arteries in the periventricular white matter

selective loss of tissue elements

neuron, oligodendrocyte, myelinated azon, astrocyte, endothelial cell

Focal motor signs

Early presence of gait disturbance

History of unsteadiness and frequent, unprovoked falls

Subcortical Syndrome

Early urinary frequency, urgency, & other urinary symptoms

Rule out other types of dementia

(Alzheimer's, Coritcal, drug induced, metabolic etc.)

Imaging studies

Risk Factor Management

both lacunar infarcts and chronic ischemia affect the deep cerebral nuclei and white matter pathways

often disrupt frontal lobe and coritco-cortico circuits leading to observed brain function deficits

• antihypertensive drugs
• diabetes management
• statins
• antiplatelet agents
• lower homocystein
• healthy lifestyle (exercise, weight loss, smoking cessation)

Personality and mood changes, apathy, depression, emotional incontience

Disease Modifying Therapy

Cognitive disorder - mild memeory deficit, psychomotor retardation, abnormal executive function

• Acetylcholinesterase inhibitors
• NMDA receptor antagonists
• Ca++ channel blockers

Treatment of behavioral symptoms

Hachinski ischemic score

• mood stabilizers
• antipsychotic medication
• antidepressants
• benzodiazepines

Total score:

< 4 suggest primary dementia (e.g. Alzheimer's)

4-7 is indeterminate

>= 7 suggest vascular dementia

Abrupt onset - 2

Stepwise deterioration - 1

Fluctuating course - 2

Nocturnal confusion - 1

Changes in personality - 1

Depression - 1

Somatic complaints - 1

Emotional incontinence - 1

Hypertention - 1

History of stroke - 2

Associated atherosclerosis - 1

Focal neurologic symptoms - 2

Focal neurologic signs - 2