Data for this review were identified from papers largely selected from the files and personal knowledge of the specialists who attended the meeting of the International Psychogeriatric Association. References were also obtained from Medline searches using the MeSH headings “Dementia, vascular”, “Dementia”, “Alzheimer disease”, and “Cerebrovascular accident”, and keywords “vascular”, “vascular dementia” and “stroke”. Other reports were identified from the reference lists from papers
ReviewVascular cognitive impairment
Section snippets
Terminology
There is now agreement that cognitive impairments associated with cerebrovascular disease extend well beyond the traditional concept of multi-infarct dementia. Variations in defining the cognitive syndrome, vascular causes, and brain changes associated with cognitive decline have resulted in various proposed diagnostic criteria. Clinically important cognitive impairments associated with vascular disease frequently do not fulfil traditional criteria for dementia, since these criteria are based
Classification of sporadic vascular cognitive impairment
Sporadic vascular cognitive impairment is a broad clinicopathological range that includes various apparently different disorders. Several clinically identifiable subtypes exist, although these are still poorly specified. The uniting feature is that vascular pathology either causes or makes a substantial contribution to the cognitive impairment (Panel).
Mixed AD with cerebrovascular disease
AD with cerebrovascular disease (mixed dementia) has been underestimated as a common cause of dementia, particularly in elderly people.29 Although common, this interaction is not recognised by current diagnostic systems, and, therefore, mixed dementia remains a difficult concept. Vascular and degenerative pathologies interact in terms of clinical expression of cognitive impairment,27, 30 and vascular dementia and AD share common pathogenetic mechanisms.42 The nature of these inter-relations and
Hereditary disorders associated with vascular cognitive impairment
The genetic contribution to stroke56 and vascular dementia is important. The underlying genetic defects for several monogenic disorders have been identified.57
Cerebral autosomal dominant arteriopathy with subcortical infarcts and leucoencephalopathy (CADASIL) is a monogenic cause of ischaemic small-vessel disease and stroke in middle-aged individuals. Clinical manifestations include transient ischaemic attacks and strokes (80%), cognitive deficits (50%), migraine with aura (40%), psychiatric
Pathophysiology of vascular cognitive impairment
Various vascular lesions may be associated with cognitive impairment.61, 62, 63, 64 The term vascular is not synonymous with ischaemic, and vascular may also be used in a broad sense related to vessel abnormalities. Some parenchymal lesions, such as diffuse white-matter changes or gliosis, can have non-vascular and vascular origins. diffuse white-matter changes or gliosis, can have non-vascular and vascular origins.
The consensus is growing that small-vessel diseases have a more important role
Cognitive and psychiatric symptoms
Because vascular cognitive impairment includes many diverse syndromes with varying causes, the striking differences in clinical presentation and course between its different forms are unsurprising. For example, single strategic infarcts will produce cognitive and other deficits that entirely depend on the location of the infarct. However, the characteristic neuropsychological profile of vascular cognitive impairment, particularly subcortical ischaemic vascular disease, is believed to frequently
Disease progression in vascular cognitive impairment
Perhaps surprisingly, in many studies progression rates in naturalistic studies of vascular dementia are similar to those in AD.72 This finding contrasts with slower progression rates for patients with vascular dementia enrolled in randomised clinical trials, in which vascular risk factors are better controlled than in naturalistic studies.73 Rates of 10–15% per year are generally accepted for progression of amnestic mild cognitive impairment, but very little is known about the natural history
Primary prevention
The formulation of any primary preventive strategy depends on knowledge of pathophysiological mechanisms. Since brain vascular disease may be the result of various pathological disorders, strategies for prevention will vary accordingly. Brain vascular disease is only one manifestation of systemic processes affecting blood vessels throughout the body. The particular factors for a given individual that result in brain vascular disease rather than vascular disease in other organs are not well
General issues
Trial designs and endpoints developed for studies of AD are not necessarily applicable to vascular cognitive impairment studies because of differences in cognitive profile, course, and rates of progression, and issues, such as variability and heterogeneity, of underlying pathology. The target in trials of vascular cognitive impairment should ideally be a homogenous group, such as patients with subcortical white-matter alterations and lacunae—ie, subcortical ischaemic vascular disease. For
Regulatory issues
Many issues are associated with drug development and in how clinical trials are done in vascular cognitive impairment because of the substantial heterogeneity in aetiopathogenesis. In addition to the difficulty of diagnosis, patients entering clinical trials vary greatly in many of the cognitive abilities tested as outcome measures. However, despite these difficulties, the development of new treatments must be encouraged.
Trials for vascular cognitive impairment should follow local, national,
Conclusions
To broaden the current narrow concepts of vascular dementia, we suggest that the whole range of cognitive impairments associated with cerebrovascular disease be recognised and studied under our proposed term vascular cognitive impairment to recognise this broad spectrum. Overall, the cognitive syndrome and brain-imaging criteria need to be refined and knowledge of the natural history, stages, and outcomes of vascular cognitive function expanded. Therefore, criteria for vascular cognitive
Search strategy and selection criteria
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