History and exam

Key diagnostic factors

common

history of stroke(s)

Onset of cognitive symptoms after occurrence of stroke(s) strongly supports a predominant vascular dementia.

difficulty solving problems

Sign of frontal cognitive syndrome.

apathy

Sign of frontal cognitive syndrome.

disinhibition

Sign of frontal cognitive syndrome.

slowed processing of information

Sign of frontal cognitive syndrome.

poor attention

Sign of frontal cognitive syndrome.

retrieval memory deficit

Sign of frontal cognitive syndrome.

frontal release reflexes

Including grasp, glabella tap, and jaw-jerk. Sign of frontal cognitive syndrome.

uncommon

focal neurological signs

Presence of focal upper motor neuron (hemispherical or bulbar) signs (e.g., hemiparesis, dysarthria, and dysphagia) supports diagnosis.

impaired gait and balance

Shuffling gait, feet 'stuck to floor', and poor balance.

Risk factors

strong

age >60 years

The most important risk factor for stroke and dementia. Ageing allows increased time for the accumulated damage to the vascular tree brought about by the other risk factors to reach the threshold level for dementia.[29][30]

obesity

Risk of vascular dementia in patients with midlife obesity (body mass index [BMI] >30) is increased 5-fold. Being overweight in midlife (BMI >25 but <30) increases the risk 2-fold.[31]​ Larger abdominal obesity in older people is also indicative of increased dementia incidence, particularly in women.[32]

hypertension

High midlife blood pressure (BP) is related to dementia. However, patients diagnosed with dementia often have lower BP at the time of diagnosis.[33][34][35]​ Nevertheless, treatment of hypertension in older adults has been shown to reduce cognitive decline.[36]

BP elevation in midlife correlates strongly with vascular damage, including atherosclerosis and atheroma. Once dementia has occurred and the vascular reserve is significantly depleted, a low BP may become problematic by increasing the likelihood of ischaemia.

cigarette smoking

Strong independent risk factor for dementia post-stroke.[13][37] Cigarette smoking has a direct effect on the vessel wall and promotes vasoconstriction.

diabetes mellitus

A confirmed risk factor for vascular dementia, but not Alzheimer’s disease, with poor glycaemic control increasing this risk in a dose-dependent manner.[38][39][40]

Conversely, in older patients, relaxed glycaemic control, as per current guidelines, reduces the risk of all-cause dementia.[41]​ Emerging evidence suggests that treatment with SGLT2 inhibitors (in particular dapagliflozin) over DPP-4 inhibitors (gliptins) is associated with a lower risk of dementia.[42]

weak

hypercholesterolaemia

Predicts stroke risk but does not necessarily predict dementia.[29] High blood cholesterol promotes atheroma.

alcohol misuse

There is some evidence of an association between high alcohol intake and vascular dementia.[43][44][45] Moderate alcohol consumption may protect against dementia.[45]

chronic kidney disease

Patients diagnosed with kidney disease have a modestly increased rate of dementia compared to the general population, mainly driven by vascular dementia. Dementia may be under-diagnosed in this population due to high mortality and other comorbidities.[46]

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