Vascular dementia: Facts and controversies

Abstract

Vascular dementia (VaD) is the second most frequent dementia after Alzheimer's disease, and is diagnosed during lifetime in 20% of demented patients. Five­year survival rate in VaD is 39%, while it is estimated to be 75% in healthy persons of the same age. It is therefore important to make correct diagnosis of VaD early in the course of the disease. Risk factors for VaD are identical to stroke risk factors, and there are significant possibilities for the prevention of vascular cognitive decline. Cognitive decline develops acutely or step­by­step within three months after stroke, but more gradual progression of intellectual decline is also possible. Neurological examination can reveal pyramidal and extrapyramidal signs, pseudobulbar palsy, gait disturbance and urinary incontinence. Neuropsychological profile comprises the loss of cognitive set shifting, decline in word fluency, verbal learning difficulties, perseverations, difficulties in complex figure copying, and in patients with cortically located lesions also problems with speech and praxia. The basis of the diagnosis is, besides history, neurological examination and neuropsychological assessment, computed tomography and/ or magnetic resonance brain imaging. Vascular risk factors control is the most important measure in VaD prevention. Modern guidelines for the treatment of cognitive decline in VaD emphasize that donepezil can be useful in the improvement of cognitive status at the level of Class IIa recommendation at the level of evidence A, while memantine may be useful in patients with mixed VaD and Alzheimer's disease dementia.

Vaskularna demencija (VaD) je posle Alchajmerove bolesti druga po učestalosti demencija, koja se zaživotno dijagnostikuje kod oko 20% svih dementnih bolesnika. Petogodišnje preživljavanje obolelih od VaD je 39%, u odnosu na 75% zdravih osoba istog životnog doba. Zbog toga je veoma važno pravovremeno i tačno postaviti dijagnozu VaD. Faktori rizika za nastanak VaD su istovetni onima za moždani udar, te postoje značajne mogućnosti za prevenciju vaskularnog kognitivnog pada. Kognitivni pad se ispoljava naglo ili postepeno tokom tri meseca od moždanog udara, ali je moguće i tzv. šunjajuće napredovanje intelektualnog propadanja. U neurološkom nalazu se mogu naći piramidalni i ekstrapiramidalni znaci, pseudobulbarna paraliza, poremećaji hodanja i inkontinencija urina. Neuropsihološki profil obuhvata teškoće promene kognitivnog seta, pogoršanje fonemske fluentnosti, oštećenje verbalnog učenja, perseverativnost, teškoće kopiranja složenog crteža, a kod kortikalno lociranih lezija i smetnje govora i praksije. Osnova dijagnoze je, pored anamneze, neurološkog pregleda i neuropsihološkog ispitivanja, nalaz na snimcima mozga skenerom i/ili magnetnom rezonancijom. Kontrola vaskularnih faktora rizika je najznačajnija mera u prevenciji VaD. Savremene preporuke za lečenje bolesnika sa VaD ističu da donepezil može biti koristan za poboljšanje kognitivnog stanja bolesnika sa VaD na nivou klase IIa preporuka, nivoa dokaza A, dok memantin može biti koristan kod bolesnika s mešovitom VaD, s elementima Alchajmerove bolesti.