Vascular Cognitive Impairment

Background

• Vascular cognitive impairment (VCI) is a spectrum of cognitive impairments associated with cerebrovascular disease, ranging from mild cognitive deficits to frank dementia.
• Clinical and neuropathologic features of vascular cognitive impairment often coexist with those of Alzheimer disease, and mixed dementia is more common than pure vascular dementia or pure Alzheimer disease.
• Causes include brain infarcts, white matter lesions, cerebral hemorrhage, atherosclerosis, small vessel disease, cerebral amyloid angiopathy, and genetic disorders.

Evaluation

• A patient or informant may report a decline in cognitive function, which may interfere with activities of daily living, with or without a history of a stroke-like event.
• A probable diagnosis of vascular dementia or vascular mild cognitive impairment can be made when all of the following are present:
  • criteria of dementia or mild cognitive impairment
  • imaging evidence of cerebrovascular disease
  • cognitive impairment and cerebrovascular disease clearly related by the timing of the onset or by the severity and pattern of diffuse subcortical cerebrovascular pathology
  • no evidence of progressive cognitive impairment suggesting nonvascular neurodegenerative disease
• Magnetic resonance imaging (MRI) is the imaging method of choice to diagnose vascular cognitive impairment (Strong recommendation).
• Consider blood tests to exclude other medical conditions that may cause dementia.
• Various cognitive tests may be used to assess the severity of cognitive impairment or dementia.

Management

• Pharmacologic therapy for cognitive and functional impairment may include:
  • donepezil 5-10 mg/day in patients with pure vascular dementia (Strong recommendation)
  • galantamine 16-24 mg/day in patients with pure vascular dementia or mixed Alzheimer disease/vascular dementia (Strong recommendation)
  • nimodipine 90 mg/day
• Dietary supplements with some evidence for efficacy for improving cognition include CDP-choline, cerebrolysin, and ginkgo biloba.
• For behavioral disturbance in patients with dementia:
  • identify and treat medical conditions or delirium contributing to the behavioral disturbance
  • behavioral interventions may reduce disruptive behaviors, but antipsychotics are NOT recommended for the treatment of aggression or psychosis
• Consider caregiver support and counseling, which may delay institutionalization in patients with dementia.