Clinical Review
Vascular Cognitive Impairment

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Cerebrovascular disease is increasingly recognized as a common cause of cognitive impairment and dementia in later life either alone or in conjunction with other pathologies, most often Alzheimer disease (AD). Progress in the field has been limited by difficulties in terminology; for example, use of the term dementia necessitates the presence of memory impairment, which is the norm in AD, but not in cognitive disorders associated with cerebrovascular disease. The term vascular cognitive impairment (VCI) has been proposed as an umbrella term to recognize the broad spectrum of cognitive, and indeed behavioral, changes associated with vascular pathology. It is characterized by a specific cognitive profile with predominantly attentional and executive impairments together with particular noncognitive features (especially depression) and a relatively stable course, at least in clinical trial populations. Subtypes of VCI have been proposed based on clinical and pathologic differences, including cortical, subcortical, strategic infarct, hypoperfusion, hemorrhagic, and mixed (with AD) type. Diagnostic criteria are emerging but require refinement and validation, especially for mixed dementias. There remain fundamental gaps in our understanding of pathophysiology, predicting prognosis and outcome, and in therapeutics. Clinical trials to date, mainly in populations selected using currently accepted criteria for vascular dementia, have generally been disappointing. A relatively modest cognitive benefit of agents such as nimodipine, memantine, and cholinesterase inhibitors has been reported, although the clinical significance of these improvements remains to be established. Further studies, focusing on particular subtypes of VCI and involving subjects at earlier stages of the disease, are required. The aim of this article is to review the concept of VCI in terms of the evidence base surrounding diagnosis, clinical features, pathophysiology, and management and to make some recommendations regarding further research in the area. It begins with a discussion on the historical background, which is important to understand the different and somewhat confusing terminology that currently exists in the field.

Section snippets

TERMINOLOGY

There remain difficulties and controversies regarding the basic issue of agreeing on a common terminology. The term vascular dementia has been and is still widely used, both clinically and in research studies, but there are problems and circularities inherent in use of the term dementia. Although several definitions exist, both DSM-IV and ICD-10 require the presence of memory impairment as an absolute requirement and then the presence of one or more (for DSM-IV) or two or more (for ICD-10)

OVERLAP WITH ALZHEIMER DISEASE

The fact that Alzheimer and vascular pathology can both contribute to cognitive impairment in an individual subject has now been clearly established. Snowdon and colleagues demonstrated that the presence of one or more infarcts in their prospective clinicopathologic study (the Nun Study) meant that a lesser degree of tangle pathology was needed to produce the same degree of cognitive impairment during life.9 It is now known that such mixed pathology occurs commonly, and in a large

DIAGNOSTIC CRITERIA

There have been several attempts to define vascular dementia. Adopting the multiinfarct model, Hachinski and colleagues proposed an ischemic scale, which was largely based on a history of stroke and the presence of focal neurologic signs.20 It provided good separation between multiinfarct dementia and those with Alzheimer disease. There are diagnostic criteria for vascular dementia in both ICD-10 and DSM-IV, but the most widely used criteria in clinical and treatment studies to date have been

Epidemiology

Vascular dementia is the second most common cause of dementia in later life.10 Historically, prevalence rates have been higher in Asian than Western countries,27 although recent studies have shown a shift from vascular to Alzheimer dementia, perhaps reflecting the rapid increase in longevity in such countries.28 Rates of vascular dementia increase with age, in the same way as for Alzheimer disease but with a slightly shallower curve. For example, it has been estimated that rates of Alzheimer

VASCULAR MILD COGNITIVE IMPAIRMENT

Cognitive impairment resulting from cerebrovascular disease (which does not meet criteria for dementia, here termed vascular mild cognitive impairment) has been relatively understudied compared with the more pre-Alzheimer concept of mild cognitive impairment (MCI).47 However, community studies have shown a higher prevalence of presumed vascular MCI than vascular dementia (2.6% versus 1.5% in the Canadian Study of Health and Aging),48 which would be expected, as would the observed age-related

PATHOPHYSIOLOGY

As indicated, various vascular lesions may be associated with cognitive impairment, including infarcts, white matter lesions, lacunas, and associated diffuse white matter changes and gliosis.4 Small-vessel disease appears particularly important and complete and incomplete infarction may occur. Commonly, white matter lesions in subcortical ischemic vascular disease include extensive periventricular and deep lesions affecting the genu/anterior capsule, anterior coronal radiata, and anterior

THERAPEUTICS

Therapy can be divided into primary prevention (preventing the occurrence of cerebrovascular disease and so its related cognitive decline in the first place), secondary prevention (preventing the exacerbation of cerebrovascular disease in those who already have it), symptomatic treatments, and disease-modifying or curative approaches. Much is known about the primary prevention of brain vascular disease, particularly in regard to stroke, and such strategies will undoubtedly be beneficial in

CONCLUSIONS

Although there has been much progress over the last decade in the understanding and classification of vascular cognitive impairment, much more needs to be done. Criteria for vascular cognitive impairment and homogeneous subtypes need to be developed, partly through more detailed study of clinical features, course, genetics, imaging changes, and pathology. There is a clear need for better understanding of the relationship between vascular pathologic change and clinical symptoms, which might lead

References (59)

  • DW Desmond

    The neuropsychology of vascular cognitive impairment: is there a specific cognitive deficit?

    J Neurol Sci

    (2004)
  • C Ballard et al.

    Anxiety, depression and psychosis in vascular dementia: prevalence and associations

    J Affect Disord

    (2000)
  • T Erkinjuntti et al.

    Efficacy of galanthamine in probable vascular dementia and Alzheimer's disease combined with cerebrovascular disease: a randomised trial

    Lancet

    (2002)
  • V Feigin et al.

    Does blood pressure lowering treatment prevents dementia or cognitive decline in patients with cardiovascular and cerebrovascular disease?

    J Neurol Sci

    (2005)
  • MB Graeber et al.

    Histopathology and APOE genotype of the first Alzheimer disease patient, Auguste D

    Neurogenetics

    (1998)
  • G Blessed et al.

    The association between quantitative measures of dementia and of senile change in the cerebral grey matter of elderly subjects

    Br J Psychiatry

    (1968)
  • VC Hachinski et al.

    Multi-infarct dementia. A cause of mental deterioration in the elderly

    Lancet

    (1974)
  • DA Snowdon et al.

    Brain infarction and the clinical expression of Alzheimer disease. The Nun Study

    JAMA

    (1997)
  • Neuropathology Group

    Medical Research Council Cognitive Function and Aging Study. MRC/CFAS: pathological correlates of late-onset dementia in a multicentre, community-based population in England and Wales

    Lancet

    (2001)
  • DS Knopman et al.

    Vascular dementia in a population-based autopsy study

    Arch Neurol

    (2003)
  • RN Kalaria

    Small vessel disease and Alzheimer's dementia: pathological considerations

    Cerebrovasc Dis

    (2002)
  • R Barber et al.

    White matter lesions on magnetic resonance imaging in dementia with Lewy bodies, Alzheimer's disease, vascular dementia, and normal aging

    J Neurol Neurosurg Psychiatry

    (1999)
  • C DeCarli et al.

    Memory impairment, but not cerebrovascular disease, predicts progression of MCI to dementia

    Neurology

    (2004)
  • IG McKeith et al.

    Prospective validation of consensus criteria for the diagnosis of dementia with Lewy bodies

    Neurology

    (2000)
  • VC Hachinski et al.

    Cerebral blood flow in dementia

    Arch Neurol

    (1975)
  • GC Roman et al.

    Vascular dementia: diagnostic criteria for research studies. Report of the NINDS-AIREN International Workshop

    Neurology

    (1993)
  • G McKhann et al.

    Clinical diagnosis of Alzheimer's disease: report of the NINCDS-ADRDA Work Group under the auspices of Department of Health and Human Services Task Force on Alzheimer's Disease

    Neurology

    (1984)
  • CG Ballard et al.

    NINDS AIREN neuroimaging criteria do not distinguish stroke patients with and without dementia

    Neurology

    (2004)
  • G Gold et al.

    Clinicopathological validation study of four sets of clinical criteria for vascular dementia

    Am J Psychiatry

    (2002)

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    Copyright © 2006 American Association for Geriatric Psychiatry. Published by Elsevier Inc. All rights reserved.