Vascular dementia

The term 'dementia' describes a loss of mental ability associated with gradual death of brain cells.

Introduction

The term 'dementia' describes a loss of mental ability associated with gradual death of brain cells.

Vascular dementia is caused by reduced blood flow to the brain because there is a problem with the blood vessels that supply it. Parts of the brain become damaged and eventually die from a lack of oxygen and nutrients.

However, unlike other forms of dementia, many cases of vascular dementia can be prevented.

Spotting the early warning signs

Many cases of vascular dementia start with early warning signs that can be treated. This early stage is known as 'vascular cognitive impairment'. If the disease is caught at this stage, the brain deterioration can be stopped and vascular dementia can be prevented.

People with vascular cognitive impairment may begin to show dementia symptoms, such as slowness of thought, difficulty with planning, memory loss, trouble with language, and mood or behavioural changes. These symptoms indicate that some brain damage has already occurred and needs to be treated immediately.

If you're worried because you think you have started to show some of the signs of vascular dementia, or you think someone you know has, see your doctor.

Signs of vascular dementia

Once vascular cognitive impairment progresses to vascular dementia, the disease can only be slowed down, not stopped. At this stage the dementia symptoms will usually be much more obvious, and may be made worse by depression.

The exact symptoms will depend on which areas of the brain have been affected.

Learn more about the symptoms of vascular dementia and its early warning signs.

What are the causes?

The most common cause of vascular dementia is narrowing and blockage of the small blood vessels deep inside the brain. The medical name for this is subcortical vascular dementia, or 'small vessel disease'.

Most cases of small vessel disease result from inheriting certain genes from your parents, so it is often seen running in families. Persistent high blood pressure is thought to play a role and may worsen the disease.

Because of the influence of high blood pressure, vascular dementia may be partly preventable. Managing high blood pressure, losing excess weight and stopping smoking may reduce your risk of developing the disease, or at least slow its progression.

Who is affected?

Vascular dementia is more common in men and usually starts before the age of 75.

It is also more common among Asian and Black Caribbean people, probably because both groups are more prone to high blood pressure.

Learn more about the causes of vascular dementia.

How is it diagnosed?

To diagnose vascular dementia or test for its early warning signs, your doctor will usually:

  • assess your symptoms
  • take your full medical history
  • assess your mental abilities
  • physically examine you
  • review the medication you are taking
  • order a range of tests, including blood tests, to rule out other possible causes of your symptoms
  • refer you for brain scans, if necessary

Find out more about the diagnosis of vascular dementia.

How is it treated, and what is the outlook?

If vascular cognitive impairment is caught before it progresses to dementia, lifestyle changes and control of blood pressure may prevent any more damage to the brain and, importantly, may prevent vascular dementia.

Recommended lifestyle changes include losing excess weight, stopping smoking and eating healthily.

Once vascular cognitive impairment progresses to vascular dementia, the disease can only be slowed down, not stopped. Medicines may help control some of the symptoms. Read more about the treatment of vascular dementia.

Rehabilitative support such as physiotherapy, occupational therapy and speech therapy aims to help people regain lost functions, and dementia activities such as 'memory cafes' and some psychological therapies can help manage symptoms.

The symptoms usually get steadily worse over the course of many years. The brain damage that causes vascular dementia is permanent and will significantly shorten life. Most people will die either from complications of dementia, such as pneumonia, or from a subsequent stroke.

Dementia affects the whole life of the person who has it, as well as their family. If you have been diagnosed with dementia, or you are caring for someone with the condition, advice and support is available to help you.

More information

Living with dementia

Find dementia activities near you

Living well with dementia

Staying independent with dementia

Dementia activities

Looking after someone with dementia

Dementia and your relationships

Communicating with people with dementia

Coping with dementia behaviour changes

Care and support

Sources of help and support

Organising care at home

Dementia and care homes

End of life planning

How you can help

Become a 'Dementia Friend'

Talk it through with a dementia nurse

Share your dementia experiences

Symptoms

The early warning signs of vascular dementia can be very similar to those of depression.

It is important that these signs are brought to the attention of your doctor, as the condition cannot be stopped once the brain impairment progresses.

Early symptoms of vascular cognitive impairment

People with vascular cognitive impairment can experience a wide range of symptoms, such as slowness of thought, difficulty with planning, memory loss, trouble with language, and mood or behavioural changes.

At this early stage, the loss of mental ability may be barely noticeable, or mistaken for something else such as depression.

It indicates that some brain damage has already occurred and treatment needs to be started immediately.

Symptoms of vascular dementia

Once the brain damage has progressed to vascular dementia, symptoms can worsen quite quickly as brain tissue begins to die.

The rate of progression varies during the course of the disease and from person to person. For example, your condition might be stable for several months or years, but strokes can then occur that lead to a sudden worsening of symptoms.

Symptoms of vascular dementia depend on which area of the brain has been damaged. Typical symptoms of vascular dementia are:

  • severe slowness of thought
  • feeling disorientated and confused
  • memory loss and difficulty concentrating
  • difficulty finding the right words
  • severe personality changes, such as becoming aggressive
  • depression, mood swings and apathy (unresponsiveness)
  • finding it difficult to walk and keep balance, frequently falling
  • having a frequent urge to urinate, without actually having a urological condition

It is possible to have a combination of vascular dementia and Alzheimer's disease. Find out about the symptoms of Alzheimer's disease.

Causes

Vascular dementia is caused by reduced blood flow to the brain because there is a problem with the blood vessels that supply it.

Without the oxygen and nourishment that this blood supply provides, brain cells become damaged and eventually die.

The most common cause of vascular dementia is narrowing and blockage of the small blood vessels deep inside the brain. The medical name for this is subcortical vascular dementia, or 'small vessel disease', which is described in detail below.

Other causes of vascular dementia include:

  • stroke – when the blood supply to part of the brain is suddenly cut off, usually after blood clots form in the blood vessels to the brain, but sometimes when a blood vessel bursts (learn more about the risk factors and causes of stroke)
  • mixed dementia – when Alzheimer's disease and stroke or small vessel disease may have caused damage to the brain
  • multi-infarct dementia – when dementia is caused by many 'mini-strokes', causing tiny but widespread areas of brain damage

Subcortical vascular dementia

The most common cause of vascular dementia is thickening and narrowing of the small blood vessels deep inside the brain.

This is known as subcortical vascular dementia, or 'small vessel disease'. The damaged or blocked blood vessels reduce blood flow to parts of the brain.

Over time, this reduced blood supply can change parts of the brain that are important for memory, attention and language, and may lead to other problems such as walking difficulties and falls (read about the symptoms of vascular dementia).

On a scan, these brain changes are seen as thinning of the white matter, which the medical term for is 'leukoaraiosis'.

In the early stages (vascular cognitive impairment), there tend to be many small areas of damaged – but not dead – brain tissue. At this stage, the damage can be stopped and dementia prevented.

In many cases, the cause of these blood vessel changes is genetic – you inherit certain genes that make the vessels more likely to narrow. Persistent high blood pressure is thought to play a role.

CADASIL

Rarely, the cause of small vessel disease is an inherited disorder called CADASIL (cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy).

In CADASIL, just a single gene mutation (faulty gene) is to blame. The gene is thought to affect the muscle cells in the blood vessel walls, making the vessels in the brain more susceptible to changes.

This tends to cause migraines followed by recurrent strokes, or 'mini-strokes', from about the age of 30. Learn more about CADASIL.

Diagnosis

If you're worried because you think you, or someone you know, may have the signs of vascular dementia, see your doctor.

The earlier the brain damage is caught, the better the chance of preventing dementia, or at least slowing down its progression.

It can be helpful if you see your doctor with a close relative or friend, because they can help you remember what is happening.

To diagnose vascular dementia or its early warning signs, you may have a number of tests and assessments, including:

  • an assessment of your symptoms, such as how long you have had memory problems
  • a full medical history, including whether you have any conditions related to vascular dementia, such as heart problems
  • a full assessment of your mental abilities, using a test such as the Montreal Cognitive Assessment
  • a physical examination
  • a review of the medication you are taking in relation to your symptoms
  • a range of tests, including blood tests, to rule out other possible causes of your symptoms, such as a vitamin B deficiency
  • brain scans, such as a computerised tomography (CT) scan,which can check for signs of a stroke or brain tumour, or a magnetic resonance imaging (MRI) scan, which can confirm a diagnosis of dementia and show any shrinking of the brain

Some of these tests can be carried out by your doctor. Some will be carried out by other specialists, such as a neurologist (an expert in treating conditions that affect the brain and nervous system), an elderly care physician, or a psychiatrist with experience of treating dementia.

Treatment

If caught early, the brain damage caused by blood vessel changes can be halted with lifestyle changes and blood pressure drugs, and dementia can be prevented.

If the brain changes have been left to progress to dementia, treatment can still help. However, treatment can only slow dementia down and cannot stop it getting worse.

This page explains the methods used to treat both vascular cognitive impairment (the early warning signs) and vascular dementia.

Treating vascular cognitive impairment

Adopting a healthier lifestyle should help to hold back any early-stage brain damage and prevent dementia. This involves:

  • eating healthily - for example, following a low-salt diet
  • losing weight, if you are overweight
  • stopping smoking, if you smoke
  • getting fit

High blood pressure is thought to be one of the main factors that causes or worsens blood vessel changes, so this may need to be controlled with medication.

Treating vascular dementia

The lifestyle changes mentioned above are also an important part of treatment for vascular dementia – they may not be able to stop the disease progressing, but they can slow it down.

Rehabilitative support such as physiotherapy, occupational therapy and speech therapy will help you to regain your lost functions as much as possible.

In the meantime, your future health and social care needs will need to be assessed and a care plan drawn up. A care plan is a way of ensuring you receive the right treatment for your needs.

Both medication and psychological therapy can help you to cope with the symptoms, although medication only has limited benefits. Some of the drugs and therapies you may be offered are described below.

Medication to lower high blood pressure

High blood pressure is thought to play a role in vascular dementia. Treating this will have the most powerful effect on improving the disease.

There is a wide range of blood pressure-lowering medicine, and a combination of drugs is sometimes needed to treat high blood pressure.

Blood pressure drugs include angiotensin-converting enzyme (ACE) inhibitors, which relax your blood vessels, and beta-blockers, which make your heart beat more slowly and with less force.

Find out more about the treatment of high blood pressure.

Acetylcholinesterase inhibitors and memantine (Alzheimer's treatments)

Acetylcholinesterase inhibitors such as donepezil (Aricept), galantamine (Reminyl) or rivastigmine (Exelon) may be prescribed for you.

These drugs have been shown to improve confusion and drowsiness in some people with vascular dementia. They work by increasing levels of the chemical acetylcholine in the brain. Acetylcholine is a neurotransmitter that sends signals from one cell to another, and is thought to be reduced in people with vascular dementia.

Memantine (Ebixa) may also help with some of the symptoms of mental decline.

However, these medications are not as effective for vascular dementia as they are for Alzheimer's disease.

The above links will take you to more information on the drugs, including their side effects.

Medication for underlying conditions

Medication is also important for treating any underlying conditions that have played a role in your vascular dementia.

For example, you may need [metformin] to treat diabetes, statins to treat high cholesterol, and an anticoagulant drug such as warfarin to reduce your risk of blood clots and further strokes.

Many people with vascular dementia also have depression. Depression has a huge impact on symptoms – for example, it can make memory problems much worse – and treating this with antidepressants can often have more of an effect on symptoms than any other drugs.

Cerebrolysin

A new drug made from pig brain cells called Cerebrolysin shows promise for vascular dementia.

A 2013 Cochrane review found that the drug improved thinking and memory. However, the evidence is not yet strong enough to recommend it as a routine treatment for vascular dementia, and it is not currently licensed in the UK.

Cognitive stimulation and reality orientation therapy

Cognitive stimulation involves taking part in activities and exercises designed to improve your memory, problem-solving skills and language ability.

Reality orientation therapy is a type of therapy that reduces feelings of mental disorientation, memory loss and confusion, while improving feelings of self-esteem.

The therapy may involve group work in a classroom, where a board prominently displays information such as:

  • the current day and date
  • the location of the classroom
  • the names of the people in the group

The group members repeat a series of tasks designed to give mental stimulation. The tasks reinforce information regarding the time, the place and the people involved in the group. You will be involved in discussions about a variety of topics, as well as taking part in word and memory games.

Reality orientation may be beneficial in some cases, but the benefits can be small and are often only apparent with continued effort. The technique is often considered unsuitable for use in care home settings.

Validation therapy

The aim of validation therapy is to explore what things were like for the person in the past and how this relates to the way they are feeling now. It works on the principle that even the most confused behaviour has some meaning for the person.

For example, if a person with dementia talks about wanting to go home to see their husband or wife who has died, telling them that their partner is no longer alive may not be the best course of action, and may confuse and upset them further.

Validation therapy is sometimes felt to be a better form of psychological therapy for treating dementia than cognitive stimulation and reality orientation therapy. This is because it focuses on the condition from an emotional, rather than factual, perspective. It views 'confused talk' as reflecting the emotional meaning of past events.

Behavioural therapy

Behavioural therapy uses a problem-solving approach where possible motivations and reasons for troublesome behaviour are identified. Different strategies are adopted to try to change that behaviour.

For example, a person with dementia may have a history of wandering out of their home or care centre because they feel restless. Therefore, encouraging them to take part in [regular physical exercise] may help to decrease their restlessness.

Behavioural therapy can be used to treat many of the behavioural problems associated with dementia, such as depression, aggression and delusional thinking. It is usually given by a carer, such as a trained friend or relative, or by an employed carer. It is supervised by a healthcare professional.

Content supplied by NHS Choices