Vascular dementia

Vascular dementia is the medical term for forms of dementia that are caused by circulatory disorders of the brain. Vascular dementia is among the most common types of dementia alongside Alzheimer’s disease.

It is very difficult to distinguish between Alzheimer’s disease and vascular dementia. In particular, elderly people with dementia often have symptoms of both disorders. This is referred to as mixed dementia. 

The symptoms of vascular dementia can differ greatly depending on the areas of the brain affected by the circulatory disorders. 

Progressive memory loss is not as significant a symptom as with Alzheimer’s disease. 

The most common type of vascular dementia, which is linked to problems with small blood vessels in the brain, has the following characteristic symptoms:

• trouble concentrating and paying attention
• slowdown, for example of thought processes
• forgetfulness
• difficulty performing everyday tasks
• listlessness or even lethargy (apathy)
• rapid mental and physical exhaustion

The following physical symptoms often occur as well:

• unsteady gait
• loss of bladder control, for example increased urinary urgency or incontinence
• difficulty swallowing and speaking
• baseless laughter and crying
• feeling faint

If larger areas of the brain are affected by a sudden reduction in blood flow (hypoperfusion), stroke symptoms such as paralysis, numbness and visual impairment may occur.

Dementia generally causes a progressive reduction, and ultimately the complete loss, of a patient’s mental capacities, specifically:

• short-term and retentive memory
• long-term memory
• concentration and ability to pay attention
• understanding and judgment
• place and time orientation
• planning and controlling activities
• drive
• language
• behavior
• mood and emotional state

Vascular dementia can be caused by various changes to the blood vessels and cardiovascular system. In all cases though, several areas of the brain receive an insufficient oxygen supply.

The following changes can affect the supply of oxygen to the brain:

• constriction of small blood vessels
• blood clots
• bleeding in the brain

Constriction of small blood vessels

Vascular dementia is most commonly caused by problems with the small blood vessels in the brain (cerebral microangiopathy). The brain’s blood vessels become so constricted due to deposits and thickened walls that the dependent areas of the brain no longer receive enough oxygen. 

This form of ischemia (insufficient blood supply) can progress slowly and spread. However, it can also cause one or more minor strokes.

Blood clots

Vascular dementia can also be caused by blood clots from neck arteries or the heart, which block the blood vessels that supply the brain. The sudden closure of the feeding blood vessel kills off the downstream brain tissue. Doctors refer to this as a cerebral infarction or ischemic stroke. 

The blood clots form on deposits in the neck arteries (arteriosclerosis) or in the heart in the case of atrial fibrillation, an irregular heartbeat. 

If multiple cerebral infarctions occur in different areas and lead to vascular dementia, this is referred to as multi-infarct dementia. However, dementia can also be triggered by a single cerebral infarction if it affects an important area for mental performance. 

If a larger artery is blocked by a blood clot, a larger area of the downstream brain tissue also dies. At least a quarter of patients who experience this type of stroke subsequently develop dementia.

Bleeding in the brain 

On far rarer occasions, vascular dementia is caused by bleeding in the brain. Such hemorrhagic strokes usually occur if feeding blood vessels are damaged by years of high blood pressure and rupture. 

About 25 percent of people who have had a stroke later develop vascular dementia. 

The same risk factors that increase the likelihood of a stroke or other cardiovascular diseases also increase the probability of vascular dementia.

In addition to a more advanced age, these primarily include health conditions such as:

• high blood pressure (hypertension)
• diabetes (diabetes mellitus)
• high cholesterol (hypercholesterolemia)
• heart conditions such as atrial fibrillation and coronary heart disease

An unhealthy lifestyle is another risk factor. The following behavioral habits have a particularly negative impact:

• smoking
• lack of physical exercise
• poor diet
• being overweight and obesity (adiposity)
• high levels of alcohol consumption

Around 250,000 people develop dementia every year in Germany, with vascular dementia accounting for 15 to 25% of these cases. Women are affected by dementia slightly more often than men.

Vascular dementia can have various symptoms depending on the causes of the circulatory disorder and the parts of the brain it affects. The way it progresses therefore varies considerably.

In the case of a reduced blood flow to the small blood vessels in the brain (microangiopathy), the loss of mental performance is progressive. If vascular dementia is caused by individual cerebral infarctions, it can sometimes only progress to a certain point and may even improve slightly. If repeated strokes occur, the person’s health condition can gradually deteriorate. 

Due to the related cardiovascular diseases, vascular dementia patients usually die sooner than people with Alzheimer’s disease. The average period between diagnosis and death is about three to five years.

A healthy lifestyle and the consistent treatment of conditions such as high blood pressure are important factors in reducing the risk of vascular dementia.

The following measures seem to have the greatest effect:

• Being physically active
• Not smoking
• Eating a balanced diet 

In addition, a good education, an active social life involving everyday activities with others, an active mind and continuous mental challenges during everyday life can also help to prevent a premature loss of mental capacities.

Doctors use a range of different methods to obtain as accurate a diagnosis as possible in the event of suspected dementia.

Neuropsychological tests

Neuropsychological tests can be used to determine whether mental abilities are affected and the extent to which the memory or ability to concentrate, for example, are impaired. 

The performance can be measured in numerical values. The doctor then compares these with average values taken from the general population.

The neuropsychological examination has two objectives:

• Firstly, to objectify the perceived reduction in mental capacity by making it measurable. This therefore shows whether or not the perceived impairments actually exist.
• Secondly, it is possible to determine the combination of symptoms present in the case at hand. These give important indications as to the cause of the dementia.

Imaging techniques

The brain is also examined using several imaging techniques to create digital cross-sectional images of it. This makes it possible to detect chronic circulatory disorders and early-stage cerebral infarctions or brain bleeds (hemorrhages). 

Such scans are performed using computed tomography (CT) and magnetic resonance imaging (MRI). Ultrasound scans of the neck arteries and special CT and MRI scans of the cerebral arteries are used to detect constrictions that can cause circulatory disorders in the brain.

Cardiovascular function tests

The doctor also takes blood samples and measures the blood pressure to detect possible high-risk disorders such as high blood pressure, diabetes or high cholesterol. 

A long-term electrocardiogram (ECG) is also used to detect issues such as atrial fibrillation. An ultrasound scan of the heart (echocardiography) can indicate problems with the heart valves or muscle.

Dementia cannot yet be cured. Treatment aims to optimally alleviate symptoms and slow the progression of the disease insofar as possible. 

As vascular dementia is caused by circulatory disorders, it is particularly important to treat existing high-risk conditions. This reduces the risk of even more brain tissue dying. 

Treating high-risk conditions

High blood pressure, diabetes mellitus and high cholesterol can be successfully treated through lifestyle changes and with medication. Heart conditions such as atrial fibrillation, coronary heart disease or cardiac insufficiency can also be treated in a targeted manner.

If blood clots have occurred in the brain, anti-clotting medication is used – ASA for vascular complaints and anticoagulants for atrial fibrillation. This can prevent further strokes. In the event of a constricted carotid artery, the narrow section can be treated through surgery or with a stent. 

Dementia medication

Alzheimer’s disease can be treated with medication that can sometimes alleviate the symptoms. This includes cholinesterase inhibitors and memantine. However, these drugs only work temporarily and do not affect the progression of the disease. They are not effective in relation to vascular dementia and can also cause side-effects. As such, they should not generally be used to treat purely vascular dementia. 

If necessary, doctors prescribe psychotropic medication to relieve symptoms such as restlessness, fear, irritability, aggressive behavior, sleep disorders and depression. However, it is important to rule out other causes for the mental symptoms first.

Non-pharmaceutical concomitant treatment

People with dementia usually require long-term care and support. This involves specialists from the fields of medicine, psychology, care, occupational therapy, physiotherapy and social work. Family carers should also be well informed and supported.

Dementia is a progressive disease. Over time, those affected become less and less able to perform everyday activities and live independently. In the advanced stage, people with dementia require extensive everyday support and, usually, permanent care.

The article “Caring for people with dementia” provides in-depth information about home care and help services.

Considering a guardianship directive, lasting power of attorney and advance healthcare directive at an early stage

The more advanced dementia becomes, the more a patient’s independence deteriorates. At some point, dementia patients will become unable to make their own important decisions. It is therefore advisable to make specific preparations with regard to guardianship and care at an early stage of the disease:

• A lasting power of attorney (LPA) or guardianship directive can be used to determine who is to be responsible for the patient’s care and for making decisions on the patient’s behalf later on. Specific conditions can also be stipulated, which must be met in order for the LPA to come into effect. 
• An advance healthcare directive, also known as a living will, allows people to specify whether and which life-sustaining measures are to be taken if they become severely ill in the future.

You can download the official form for a lasting power of attorney for health and welfare (“Vorsorgevollmacht” in German) from the website of the Federal Ministry of Justice and Consumer Protection. 

Self-help and residential nursing care services

In the later stages of dementia, psychosocial support, nursing care and the provision of relief for family carers become increasingly important.

Local services can be a first port of call for obtaining the support needed, e.g., facilities providing day-time care or hourly care for people with dementia, training courses in caring for those with the disease or discussion groups for relatives.

The main caregiver is also entitled to request short-term and respite care if they themselves become ill or need some time off.

Furthermore, self-help groups provide the opportunity to talk to other people who have family members with vascular dementia or who provide care at home for people with dementia.

The Federal Ministry of Health (BMG) website provides an online guide on dementia and an online care guide (in German) with information for patients and their relatives.

A short guide published by the German Agency for Quality in Medicine (Ärztliches Zentrum für Qualität in der Medizin – ÄZQ) is dedicated to the challenges faced by family carers.

Information about dementia and self-help can be obtained from the website of the German Alzheimer’s Society (Deutsche Alzheimer Gesellschaft e.V.).

The German Brain Foundation (Deutsche Hirnstiftung e.V. – DHS) offers extensive information about dementia as well as personalized advice through online inquiries and telephone consultations.