What IS vascular dementia?

What IS Vascular Dementia?

“Not to brag, but I haven’t had a mood swing in like 7 minutes!”

In a nutshell, VaD is damage to some parts of the brain due to reduced blood flow. Blood clots in the brain impact: short-term/long-term memory loss, reduced concentration, bladder control and hallucinations/delusions. In a silly way, I am happy scientists added the letter “a” to VaD. I don’t want to tell people that I am dying of V.D.! 

Most people with vascular dementia start having symptoms after age 65, although the risk is significantly higher for people in their 80’s and 90’s. But I developed progressive vascular dementia at the age of 57! I had a few strokes in my 40’s due to high-stress jobs and long hours. Plus, I was a very type “A” personality. I also began developing blood clots in my legs around that time that continued for years despite blood thinners and therapy. In my mid-fifties, I developed a blood clot in my brain that was dissolved with chemicals before an emergency surgery was required. 

Vascular dementia can cause different symptoms depending on where the damage is located in the brain. Most people with vascular dementia have trouble with memory, balance and speech. Others may have trouble with organization and solving complex problems, slowed thinking or being easily distracted. People with vascular dementia may also have mood changes, including irritability, withdrawal, aggression, and depression. 

So, what IS VaD? Vascular dementia reflects the array of conditions that can impair the blood's ability to circulate to the brain. Once the blood flow decreases, the neurons near the veins shut down and are beyond repair. Between 1 percent to 4 percent of people over the age of 65 have vascular dementia. And the risk of developing it increases dramatically with age. 

Vascular dementia is estimated to account for between 10 percent to 20 percent of all dementia cases. People with vascular dementia often display multiple cognitive problems, including:

Aphasia: a language disorder. where someone is unable to find the right words or may say them incorrectly, or receptive aphasia, where the ability to understand, receive and interpret language is impaired. Strangely enough, I struggle a great deal right now speaking English, my primary language. Yet, I am also bilingual in Spanish, which has become heightened for me. That area of my brain in compensating for my other language challenges. Good thing I live in San Antonio, Texas! 

Apraxia: a neurological disorder affecting the ability to control motor movements and gestures. Individuals may be born with apraxia, or they may acquire apraxia through brain injury. Apraxia can affect the ability to move facial muscles or the ability to move legs, feet, and toes. The disorder can also affect communication skills. For me, my first noticeable issue came with my ability to walk straight. I increasingly fight my legs in their desire to go to the left when I am trying to walk forward. This quickly led to my dependence on a walker. 

Agnosia: the impairment of the ability to receive or correctly understand information from the senses of hearing, smell, taste, touch, and vision. They also might not be able to recognize loved ones as the disease progresses. Agnosia does not have to happen all the time. I have had issues, randomly, with not being able to recognize family members and friends. I have also had difficulties with vision because I have to concentrate so hard to see things and comprehend what they are. However, I have been blessed in the fact that my senses of smell, taste and touch have been unaltered (as of this writing). 

Amnesia, medically known as “C.R.S. or Can’t Remember Shit”, refers to memory loss and is often the most easily visible and common sign of Alzheimer's disease. Memory loss in Alzheimer's disease typically begins with the short-term memory and progresses to a decline in long-term memory.Amnesia can be caused by a head injury, sustained brain damage, a stroke, alcohol abuse, or psychogenic amnesia. the result of a person consciously or subconsciously blocking out a part of their memory, often as a result of a highly traumatic event. Brain tumors, brain infection, or serious mental illness are other causes of amnesia. Or, a combination of many factors. I have had a history of strokes, epilepsy, and a psychogenic event in my childhood that required psychiatric therapy and medication for depression. And my diabetes doesn’t help! 

More on Vascular Dementia 

Vascular dementia is the second most common type of dementia (after Alzheimer’s disease). The word dementia describes a set of symptoms that can include memory loss and difficulties with thinking, problem-solving or language. In vascular dementia, these symptoms occur when the brain is damaged because of problems with the supply of blood to the brain. This factsheet outlines the causes, types and symptoms of vascular dementia. It looks at how it is diagnosed and the factors that can put someone at risk of developing it. It also describes the treatment and support that are available.

Vascular dementia is caused by reduced blood supply to the brain due to diseased or damaged blood vessels.

To be healthy and function properly, brain cells need a constant supply of blood to bring oxygen and nutrients. Blood is delivered to the brain through a network of vessels called the vascular system. If the vascular system within the brain becomes damaged – so that the blood vessels leak or become blocked – then blood cannot reach the brain cells and they will eventually die.

This death of brain cells can cause problems with memory, thinking or reasoning. Together these three elements are known as cognition. When these cognitive problems are bad enough to have a significant impact on daily life, this is known as vascular dementia.

There are several different types of vascular dementia. They differ in the cause of the damage and the part of the brainthat is affected. The different types of vascular dementia have some symptoms in common and some symptoms that differ. Their symptoms tend to progress in different ways.

Stroke-related dementia

A stroke happens when the blood supply to a part of the brain is suddenly cut off. In most strokes, a blood vessel in the brain becomes narrowed and is blocked by a clot. The clot may have formed in the brain, or it may have formed in the heart (if someone has heart disease) and been carried to the brain. Strokes vary in how severe they are, depending on where the blocked vessel is and whether the interruption to the blood supply is permanent or temporary.

Post-stroke dementia

A major stroke occurs when the blood flow in a large vessel in the brain is suddenly and permanently cut off. Most often this happens when the vessel is blocked by a clot. Much less often it is because the vessel bursts and bleeds into the brain. This sudden interruption in the blood supply starves the brain of oxygen and leads to the death of a large volume of brain tissue.

Not everyone who has a stroke will develop vascular dementia, but about 20 per cent of people who have a stroke do develop this post-stroke dementia within the following six months. A person who has a stroke is then at increased risk of having further strokes. If this happens, the risk of developing dementia is higher.

Single-infarct and multi-infarct dementia

These types of vascular dementia are caused by one or more smaller strokes. These happen when a large or medium-sized blood vessel is blocked by a clot. The stroke may be so small that the person doesn’t notice any symptoms. Alternatively, the symptoms may only be temporary – lasting perhaps a few minutes – because the blockage clears itself. (If symptoms last for less than 24 hours this is known as a ‘mini-stroke’ or transient ischemic attack (TIA). 

If the blood supply is interrupted for more than a few minutes, the stroke will lead to the death of a small area of tissue in the brain. This area is known as an infarct. Sometimes just one infarct forms in an important part of the brain and this causes dementia (known as single-infarct dementia). Much more often, a series of small strokes over a period of weeks or months lead to a number of infarcts spread around the brain. Dementia in this case (known as multi-infarct dementia) is caused by the total damage from all the infarcts together.

Subcortical dementia

Subcortical vascular dementia is caused by diseases of the very small blood vessels that lie deep in the brain. These small vessels develop thick walls and become stiff and twisted, meaning that blood flow through them is reduced. Small vessel disease often damages the bundles of nerve fibers that carry signals around the brain, known as white matter. It can also cause small infarcts near the base of the brain. Small vessel disease develops much deeper in the brain than the damage caused by many strokes. This means many of the symptoms of subcortical vascular dementia are different from those of stroke-related dementia. Subcortical dementia is thought to be the most common type of vascular dementia.

Mixed dementia (vascular dementia and Alzheimer’s disease)

At least 10 per cent of people with dementia are diagnosed with mixed dementia. This generally means that both Alzheimer’s disease and vascular disease are thought to have caused the dementia. The symptoms of mixed dementia may be like those of either Alzheimer’s disease or vascular dementia, or they may be a combination of the two.

Symptoms of subcortical vascular dementia vary less. Early loss of bladder control is common. The person may also have mild weakness on one side of their body or become less steady walking and more prone to falls. Other symptoms of subcortical vascular dementia may include clumsiness, lack of facial expression and problems pronouncing words.

Progression and later stages

Vascular dementia will generally get worse, although the speed and pattern of this decline vary. Stroke-related dementia often progresses in a ‘stepped’ way, with long periods when symptoms are stable and periods when symptoms rapidly get worse. This is because each additional stroke causes further damage to the brain. Subcortical vascular dementia may occasionally follow this stepped progression, but more often symptoms get worse gradually, as the area of affected white matter slowly expands.

Over time a person with vascular dementia is likely to develop more severe confusion or disorientation, and further problems with reasoning and communication. Memory loss, for example for recent events or names, will also become worse. The person is likely to need more support with day-to-day activities such as cooking or cleaning.

As vascular dementia progresses, many people also develop behaviors that seem unusual or out of character. The most common include irritability, agitation, aggressive behavior and a disturbed sleep pattern. Someone may also act in socially inappropriate ways.

Occasionally a person with vascular dementia will strongly believe things that are not true (delusions) or – less often – see things that are not there (hallucinations). These behaviors can be distressing and a challenge for all involved.

In the later stages of vascular dementia someone may become much less aware of what is happening around them. They may have difficulties walking or eating without help and become increasingly frail. Eventually, the person will need help with all their daily activities.

How long someone will live with vascular dementia varies greatly from person to person. On average it will be about five years after the symptoms started. The person is most likely to die from a stroke or heart attack.

A person who has had a stroke, or who has diabetes or heart disease, is approximately twice as likely to develop vascular dementia. Sleep apnea, a condition where breathing stops for a few seconds or minutes during sleep, is also a possible risk factor. Someone can reduce their risk of dementia by keeping these conditions under control, through taking prescribed medicines (even if they feel well) and following professional advice about their lifestyle.

There is some evidence that a history of depression also increases the risk of vascular dementia. Anyone who thinks they may be depressed should seek their doctor’s advice early.

Cardiovascular disease – and therefore vascular dementia – is linked to high blood pressure, high cholesterol and being overweight in mid-life. Someone can reduce their risk of developing these by having regular check-ups (over the age of 40), by not smoking, and by keeping physically active. It will also help to eat a healthy balanced diet and drink alcohol only in moderation.

Aside from these cardiovascular risk factors, there is good evidence that keeping mentally active throughout life reduces dementia risk. There is some evidence for the benefits of being socially active too.

Researchers think there are some genetic factors behind the common types of vascular dementia, and that these are linked to the underlying cardiovascular diseases. Someone with a family history of stroke, heart disease or diabetes has an increased risk of developing these conditions. Overall, however, the role of genes in the common types of vascular dementia is small.

People from certain ethnic groups are more likely to develop cardiovascular disease and vascular dementia than others.

There is no single test for vascular dementia. The general practioner will first need to rule out conditions that can have similar symptoms, particularly depression. Symptoms could also be caused by infections, vitamin and thyroid deficiencies (diagnosed from a blood test) and side effects of medication.

The doctor will also talk to the person about their medical history (example, high blood pressure or diabetes). This will include questions about dementia or cardiovascular disease in close family members. The doctor will probably do a physical examination and will ask about how the person’s symptoms are currently affecting their life. The general practioner or a practice nurse may ask the person to do some tests of mental abilities. It is often helpful if a close friend or family member accompanies the person to medical appointments. They may be able to describe subtle changes that the person themselves has not noticed, such as starting to struggle with daily activities.

The general practioner may feel able to make a diagnosis of vascular dementia at this stage. If not, they will generally refer the person to a specialist. This might be an old-age psychiatrist (who specializes in the mental health of older people) based in a memory service, or a geriatrician (who specializes in the physical health of older people) in a hospital. 

The specialist will assess the person’s symptoms in more detail. The way that symptoms developed – in steps or more gradually – may suggest different underlying diseases. The person’s thinking and other mental abilities will also be assessed further with a wider range of tests. In someone with vascular dementia, the test might show slowness of thought and difficulties thinking things through, which are often more common than memory loss.

A person suspected of having vascular dementia will generally have a brain scan to look for any changes that have taken place in the brain. A scan such as CT (computerized tomography) or MRI (magnetic resonance imaging) may rule out a tumor or build-up of fluid inside the brain. These can have symptoms like those of vascular dementia. A CT scan may also show a stroke, or an MRI scan may show changes such as infarcts or damage to the white matter. If this is the case, the brain scan will be very helpful in diagnosing the dementia type, rather than simply ruling out other causes.

If the person has dementia, and the circumstances mean it is best explained by vascular disease in the brain, a diagnosis of vascular dementia will be made. For example, the dementia may have developed within a few months of a stroke, or a brain scan may show a pattern of disease that explains the dementia symptoms.

The diagnosis should be communicated clearly to the person and usually also those closest to them, along with a discussion about the next steps. 

“What IS Vascular Dementia?”, 1998-2015, https://doctordementia.com/2015/09/29/what-is-vascular-dem. Accessed December 2018. 

“Welcome to my brain! You may want to buckle up. It’s a bumpy ride”