Approach

As with all other forms of dementia, care for people with vascular dementia should focus on ensuring the safety of the patient and others, and giving reassurance and support to the patient and carers. Treatment will be determined by the particular symptoms of the individual patient and the needs and responsiveness of the carers.

Prevention of further cerebrovascular disease by optimal control of major risk factors in people with a history of stroke or transient ischaemic attack (TIA) is the main goal of treatment for patients with vascular dementia.

Choice of preventive treatment is influenced by the likely aetiology of the focal brain injury, and the type and location of the vascular lesion.[71]​ This includes patients with atherosclerotic ischaemic disease and cardioembolic disease. Atherosclerotic disease refers to disease without a definitive cardiac source for cerebral emboli and suspected pathogenesis of artery-to-artery embolism. Cardioembolic disease refers to disease with a definitive cardiac source for cerebral emboli (e.g., atrial fibrillation, valvular heart disease, left ventricular thrombus).

A further aspect of care comprises interventions for the management of behavioural and psychological symptoms.

Prevention of cerebrovascular disease

The main treatment options for preventing cerebrovascular disease are as follows:

  • For patients with atherosclerotic disease: antiplatelet therapy, plus carotid endarterectomy or carotid angioplasty and stenting for those with carotid stenosis[71]​​

  • For patients with cardioembolic disease: anticoagulation.[71]​​

Lifestyle modification interventions should also be started as applicable.

Antiplatelet therapy

Aspirin is useful for secondary prevention of cerebrovascular disease. There is no good evidence that aspirin is effective in treating cognitive symptoms in patients with vascular dementia.[72]​ Evidence supports the use of aspirin monotherapy, or combination treatment with aspirin plus clopidogrel or aspirin plus ticagrelor, for preventing further infarction in patients with stroke or TIA relating to atherosclerotic or small-vessel disease.​​[71]​ The selection of antiplatelet agent should be individualised on the basis of patient risk factor profiles, tolerance, relative known efficacy of the agents, and other clinical characteristics.

Carotid endarterectomy or carotid angioplasty and stenting

Carotid endarterectomy is the preferred treatment for unilateral symptomatic carotid stenosis (grade >70%) in patients who have had a non-disabling stroke or TIA within the last 6 months.[71]​ Carotid angioplasty and stenting may be an alternative to carotid endarterectomy for symptomatic patients at average or low risk of complications associated with endovascular intervention when the diameter of the internal carotid artery lumen is reduced by >70% by non-invasive imaging or >50% by catheter-based imaging or non-invasive imaging with corroboration, and the anticipated rate of periprocedural stroke or death is <6%.[71] ​See Carotid artery stenosis. For patients older than 70 years, carotid endarterectomy may be associated with improved outcome compared with carotid angioplasty and stenting, particularly when arterial anatomy is unfavourable for endovascular intervention.[71]​​

Anticoagulation

Warfarin is highly effective in reducing the risk of cardioembolic stroke in patients with atrial fibrillation.[73]​ The direct-acting oral anticoagulants apixaban, dabigatran, rivaroxaban, and edoxaban are also effective in reducing cardioembolic stroke in patients with non-valvular atrial fibrillation.​[73]​ See Established atrial fibrillation.

Lifestyle modification

Aggressive risk factor modification to reduce the risk of stroke should also be started, including physical activity, dietary modification, cholesterol lowering, blood pressure control, and diabetes/glucose control.

Patients who are able to exercise should undertake 40 minutes of moderate- to vigorous-intensity exercise 3 to 4 times per week.​ Smokers should be advised to stop smoking. Patients with a high alcohol intake should be advised to reduce their intake or stop drinking altogether.[71]

Treatments to improve cognitive symptoms or to prevent worsening of dementia related to cerebrovascular disease

Cholinesterase inhibitors and memantine

The effects of cholinesterase inhibitors and memantine are modest and of uncertain clinical benefit in patients with dementia with a solely vascular aetiology.[74][75][76][77][78][79][80]​​ However, co-existing Alzheimer’s disease (AD) may warrant such treatment because cholinesterase inhibitors and memantine have some benefit in these patients.[79][81]​ Mixed dementia comprising co-existing AD and vascular dementia is thought to occur in a significant proportion of patients with dementia.[28][82]

Cholinesterase inhibitors are indicated for mild to severe AD. Clinical benefits are modest, but have been reported to continue beyond 1 year with ongoing treatment.[81][83]​ Memantine is indicated for moderate to severe AD.[79] Co-administration of memantine with a cholinesterase inhibitor may be considered as the severity of AD worsens. Memantine can be given as sole treatment if cholinesterase inhibitors are contraindicated, are not tolerated, and/or have been shown to be ineffective. Donepezil and galantamine appear to have the greatest effect on cognition for patients with vascular cognitive impairment, and so patients may wish to consider these, given the absence of other treatment options.[80]​ Cholinesterase inhibitors are known to have cardiovascular effects, as well as neurological, and with long-term treatment, there is good evidence to confirm that they reduce all-cause mortality in dementia patients.[84]

Antihypertensive drugs

The results of two trials suggested an effect of both the ACE inhibitor perindopril and the calcium-channel blocker nitrendipine in the prevention of both AD and dementia related to strokes.[85] Systematic reviews have found benefit with nimodipine, another calcium-channel blocker, and also ACE inhibitors and diuretics.[86][87] [ Cochrane Clinical Answers logo ] However, evidence about whether blood pressure lowering treatment prevents or delays cognitive decline in patients with or without prior cerebrovascular disease is mixed.[88][89][90]

Antihypertensive treatment is of demonstrated benefit for the prevention of cerebrovascular disease and should be used for this purpose, an indirect effect of which may be the prevention of stroke-related cognitive decline.

Statins

Studies of statin use to improve cognitive function have found no clear benefit.[91][92]​ Statin treatment has been shown not to prevent cognitive decline or dementia in people at risk of vascular disease.[93]​ There is no robust evidence to confirm suggested associations between aggressive lowering of LDL cholesterol and toxic effects on the brain, including increased risk of dementia and haemorrhagic stroke.[94]

The main role of statins in the treatment of vascular dementia is in preventing further ischaemic events. There is good evidence to support the use of statins in secondary stroke prevention.[95][96]

Statins may be indicated for primary prevention of cerebrovascular disease in patients with cardioembolic disease and elevated low-density lipoprotein cholesterol or diabetes, or following a risk discussion between the clinician and the patient.[96]

Managing diabetes

Optimising glucose control in patients with diabetes can reduce macrovascular and microvascular disease risk.[97]

Non-pharmacological treatments for cognitive impairment

Cognitive stimulation therapy or cognitive training may improve cognitive function among patients with mild to moderate dementia, but evidence is of low quality.[98][99][100]

Cognitive rehabilitation is helpful in enabling people with mild to moderate dementia to improve their management of everyday activities through a personalised solution-focussed approach.​[101]

Management of behavioural and psychological symptoms

Several behavioural and psychological symptoms are associated with vascular dementia and mixed dementia, and treating these is an important part of dementia care. These include depression, apathy, agitation, aggression, and sleep disturbance.

Non-pharmacological strategies for managing behavioural and psychological symptoms

Families and carers should be encouraged to promote independent functioning for as long as possible. Symptoms of apathy or depression may be improved by encouraging social gatherings and activities (such as gardening, cleaning, and setting the table) to provide the person with routine and foster a sense of utility. Actions that can be useful in reducing agitation include explaining carer actions in advance, giving written instructions, and using calendars, clocks, and charts to help patients stay oriented to the time and place. Patients with agitation may also respond well to massage therapy, animal-assisted intervention and personally-tailored activities.[102]​ There is also some evidence that personally tailored activities can reduce challenging behaviour in people with dementia living in the community.[103]

Psychological interventions (e.g., cognitive behavioural therapy, interpersonal therapies) may reduce depression and anxiety in people with dementia, but are not as effective as in people who do not have dementia.[104][105]​ Non-drug interventions such as massage therapy, and cognitive stimulation combined with exercise and social interaction can be more effective than medicine to treat depression in dementia patients.​[106]

Other strategies to reduce behavioural difficulties may include: scheduled toileting times and prompting to encourage voiding; playing music, especially during meals and bathings; and encouraging walking or light forms of exercise.

Although it is generally agreed that sleep disturbance is linked to dementia and reducing cognition, evidence is lacking as to which interventions are most effective to overcome or prevent this.[107][108]

Depression: pharmacological treatment

Depression is common in patients with vascular dementia.[109] The available evidence does not provide strong support for the efficacy of antidepressants for treating depression in dementia.[110] However, clinical consensus supports undertaking a trial of an antidepressant to treat clinically significant depression in people with dementia.[111]

Selective serotonin-reuptake inhibitors (SSRIs) such as sertraline, citalopram, and escitalopram are preferred. SSRIs with a longer half-life (i.e., fluoxetine), those with increased potential for drug-drug interactions mediated by cytochrome P450 (fluoxetine, paroxetine, fluvoxamine), and those known to be more activating (e.g., paroxetine) should be used with caution. Mirtazapine, an atypical antidepressant, is appropriate when poor appetite and insomnia are present.

SSRIs and mirtazapine increase the risk of QT prolongation and should be used with caution in patients with conditions that also increase the risk of QT prolongation (e.g., bradycardia, heart failure, cardiomyopathy, stroke, myocardial infarction); regular ECG monitoring is needed. There is an increased risk of bleeding with SSRIs, so caution and monitoring are needed if the patient is taking an anticoagulant or antiplatelet agent. Mirtazapine can cause orthostatic hypotension and so should be used with caution in patients with cerebrovascular disease that can be exacerbated by hypotension.

Serotonin-norepinephrine reuptake inhibitors may be appropriate depending on patient preference, comorbidity, and clinician experience. Tricyclic antidepressants should not be used because of the risk of significant cardiovascular adverse effects and of lethal overdose.

Agitation and aggression: pharmacological treatment

One Cochrane review found that the SSRIs citalopram and sertraline were associated with a reduction in symptoms of agitation compared with placebo in people with dementia, although there was no specific evidence for people with vascular dementia.[112] See the section on Depression: pharmacological treatment above for cautions on SSRI use.

Antipsychotics should be avoided in people with vascular dementia because of the reported increased incidence of stroke and myocardial infarction in people taking these drugs, in addition to evidence of increased mortality with both typical and atypical antipsychotic use in patients with dementia.[113][114][115][116]

Supportive care

The first step after diagnosis is to provide education, support, and resources to the patient and their families and carers.[64] Information should cover topics such as how symptoms are likely to progress, future care needs (including early care planning), and advance directives or power of attorney for health care. The benefits and risks of non-pharmacological and pharmacological treatments should be discussed with the patient and family, so that informed decisions can be made. A social worker, psychologist, or other mental health professional should be made available to provide emotional support and psychosocial input.

Carer needs

Families and carers should be an integral part of these conversations. They should be advised about further sources of information and carer support groups; the latter have been shown to be beneficial.[117]

Environmental review

A home safety evaluation should be undertaken, as well as an assessment of transport, driving, and self-care needs by an occupational therapist.[118] Impaired gait and balance are typical of vascular dementia, so it is important that falls risk is assessed, and interventions to mitigate this risk put in place.[119]

End-of-life care

Late-/end-stage care includes palliative measures, end-of-life choices, and discussing goals of care with the family.[120][121] It is important to review these issues in late-stage dementia, as overly aggressive care such as percutaneous endoscopic gastrostomy feeding tubes can worsen morbidity and not improve quality of life or longevity.[122] Many patients and families do not want extreme measures if there is no possibility of independent function. Exploring family and patient preferences in the context of medical literature and information is very helpful.[64]

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