Vascular dementia
Vascular dementia is a lasting decline in thinking, memory and the ability to manage everyday life, caused by parts of the brain no longer getting enough blood.
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On this page
- How it differs from Alzheimer's disease
- How the person changes over time
- Where it comes from
- Why the course really can be influenced
- A sudden change for the worse: when to call an ambulance
- Much worse within a few days: look for a cause
- How the diagnosis is made
- What helps in everyday life
- Online consultation
Medicines commonly prescribed for Vascular dementia
For informational purposes only. Always consult a doctor before using any medicine.
Dosage form: TABLET, 40 mg simvastatinActive substance: simvastatinManufacturer: Laboratorios Combix S.L.U.Prescription requiredDosage form: TABLET, 10 mgActive substance: memantineManufacturer: Laboratorios Alter S.A.Prescription requiredDosage form: TABLET, 20 mgActive substance: simvastatinManufacturer: Teva Pharma S.L.U.Prescription required
Vascular dementia is a lasting decline in thinking, memory and the ability to manage everyday life, caused by parts of the brain no longer getting enough blood. It is the second most common cause of dementia after Alzheimer's disease, and the two are confused constantly. The difference is not academic. In vascular dementia we know exactly what damaged the brain: the same changes in the blood vessels that cause strokes. Which means there is something to act on. Nothing brings back cells that have already died, but the rate at which the next ones are lost depends a great deal on how early somebody got to grips with blood pressure, cholesterol, blood sugar and heart rhythm.
How it differs from Alzheimer's disease
The first difference is the shape of the illness. Vascular dementia often moves in steps: for months or years things barely change, then over two or three weeks there is a clear drop, and a new plateau settles in. Relatives can usually name a rough date: "after the summer he was a different man." In Alzheimer's disease the slope is smooth and invisible from one day to the next. Not everyone has the steps — when the smallest vessels are affected the decline can also be gradual — but where they exist they are a strong argument for a vascular cause.
The second difference matters more for recognising it: what comes to the fore is not forgetfulness but slowness. The person understands everything, but thinks and answers more slowly, and gets lost wherever several steps have to follow one another: paying the bills, packing for a trip, cooking a meal. Holding attention is hard, switching between tasks is hard, starting is hard. Memory may be relatively well preserved, and a prompt often helps the person retrieve something — in Alzheimer's disease a prompt usually does not help at all.
The third difference is visible from outside. Walking and balance change early: steps become short and shuffling, turning gets harder, the person trips and steadies themselves on the furniture. Passing water becomes more frequent, and leakage appears. Mood changes too: apathy, low spirits, and sometimes tears or irritation that arrive suddenly and out of proportion to what caused them. All of this can appear before the family suspects any problem with memory. Fairly often both illnesses are present at once — this is called mixed dementia, and the vascular part is still worth treating.
How the person changes over time
Early signs are easily put down to age, tiredness or depression, and usually are. It is worth paying attention when several things turn up together in an older person: noticeably slower thinking, jobs abandoned half done, muddle over the order of familiar tasks, worse handling of money, new irritability or new indifference, giving up driving or driving badly.
Later come disorientation in time and in unfamiliar places, difficulty finding words, forgetting recent events, and growing dependence on help with eating and washing. Walking becomes as big a problem as memory: falls, and the fear of falling, narrow life all by themselves. How fast any of this happens cannot be predicted — some people hold the same level for years, others lose their independence within a couple of years. That is why it makes more sense to talk about what can be done in a particular situation than about the outlook in general.
Where it comes from
There is a single cause: the brain is short of blood. There are three routes to it.
- Small vessel disease. The finest arteries deep inside the brain narrow, patches of tissue live on short rations for years and gradually die off. This is the commonest form, and it is the one that produces slowness, disturbed walking and bladder trouble.
- A stroke. A large vessel is blocked by a clot and part of the brain dies at once. Not everyone develops dementia afterwards, but the risk rises many times over.
- Many small, silent brain infarcts. Each one on its own may pass unnoticed, or as a brief spell of weakness or slurred speech that clears within the hour. Accumulating, they produce the same picture.
What makes all of the above more likely: high blood pressure, which is the leading factor, smoking, diabetes, high cholesterol, atrial fibrillation and other heart disease, excess weight, inactivity, regular alcohol and sleep apnoea. Some things cannot be changed — age, a family history of stroke, and rare inherited diseases of the brain's blood vessels that show up unusually early. But the unchangeable factors are in the minority on that list.
Why the course really can be influenced
This is the key practical difference from every other dementia. What is treated here is not the dementia itself but the thing that causes strokes, and that reduces the number of new injuries to the brain. The measures are entirely concrete: blood pressure brought down to target, cholesterol lowered, blood sugar controlled if there is diabetes, smoking stopped, atrial fibrillation treated with medicines that reduce clotting. Regular walking, weight loss and cutting down on alcohol go with them.
It is worth being honest in both directions. None of these steps restores what has been lost, and none guarantees there will be no further decline. But this is the only dementia in which treatment has an obvious point of attack, and the earlier it starts the more it is worth. Someone whose blood pressure has been running high for years should see it this way: dealing with it now is not abstract prevention, it is a decision about what the next year will look like.
A word about the medicines prescribed in Alzheimer's disease: in pure vascular dementia they are not indicated and give no noticeable benefit. They are used where Alzheimer's disease has been added to the vascular damage, and that is a specialist's decision. Self-bought courses of "circulation boosters" for the brain do not change the course of dementia, and they draw time and attention away from the things that do count — blood pressure and heart rhythm.
A sudden change for the worse: when to call an ambulance
Here a warning about stroke belongs more than anywhere else, because stroke is a direct part of this illness rather than a distant hazard. Call an ambulance straight away if any one of these appears suddenly:
- the face has dropped on one side, the corner of the mouth is down, the person cannot smile evenly;
- an arm or a leg has become weak or numb, usually on one side, and a raised arm drifts down;
- speech has become slurred, words are muddled, or the person cannot follow what is said to them;
- sudden loss or doubling of vision, sudden loss of balance, an inability to stand;
- a sudden very severe headache unlike any before, particularly with vomiting or reduced consciousness.
Timing decides everything here: the treatments that can dissolve a clot or pull it out work in the first few hours. Spain, Italy, Portugal, Poland and Ukraine all use the single emergency number 112; if the ambulance number in your country is different, use that one. Do not wait until morning and do not give blood pressure medicine on your own judgement.
Much worse within a few days: look for a cause
This is one of the most useful things a carer can know. If a person with dementia becomes far more confused than usual within a few days, or even within a day, stops recognising the household, starts seeing or hearing things that are not there, becomes restless at night and drowsy by day, this is almost never "the illness moving on". It is acute confusion set off by something from outside, and the cause is nearly always reversible.
What to look for first: a urine infection, which in older people often runs without pain and without a temperature; pneumonia; dehydration, especially in hot weather or with vomiting or diarrhoea; constipation; any pain the person cannot report, from a tooth to a fracture after a fall; and retention of urine. And always a new medicine, or a changed dose of an old one, including sleeping tablets, antihistamines and drugs for incontinence.
The right move is to contact a doctor the same day and ask for the cause to be looked for, rather than for the sedative dose to be increased. An examination plus urine and blood tests is usually enough. If the cause is found and put right, the person mostly returns to roughly their previous level. If it is all filed under "the dementia is progressing" and nothing is done, the state can become fixed — and then the loss really is permanent.
How the diagnosis is made
There is no single test or scan that proves vascular dementia. The diagnosis is assembled from a detailed account of what changed and in what order — the account given by those close to the person matters a great deal here, because people often do not notice the changes in themselves — from the history of blood pressure, diabetes, strokes and arrhythmia, from a neurological examination that includes walking and balance, and from short tests of memory, attention and planning. To this is added an MRI or CT scan of the brain, which shows the traces of previous infarcts and the changes in white matter typical of small vessel disease.
There is a second half of the work-up that sometimes gets forgotten: looking for conditions that worsen thinking in their own right and can be treated — an underactive thyroid, vitamin B12 deficiency, depression, sleep apnoea, heavy drinking, side effects of medication. At the same time blood pressure is measured over several days, an ECG is done so that atrial fibrillation is not missed, and cholesterol and blood sugar are checked. In other words, the list of what needs working on is drawn up straight away. It is worth seeing a doctor without waiting for obvious memory failures: it is at the early stage that acting on the vascular factors pays off most.
What helps in everyday life
Work with a rehabilitation therapist and exercise within the person's capacity keep walking going and cut the risk of falls, and falls are one of the main reasons independence is lost in this illness. The home is worth reorganising in advance: take up loose rugs, move cables, leave a light on in the hall and bathroom at night, fit rails where somebody has to stand up and turn. A simple daily routine helps, as do a large clock showing the date, notes and lists, one task at a time and short sentences without several questions in a row. Conversation and activities that keep language and thinking in use work better than people expect: isolation speeds up decline in itself. Poor sight and poor hearing add to confusion, so glasses and a hearing aid are not about comfort, they are about the head. Depression is common in vascular dementia and responds well to treatment, so low mood is worth raising with the doctor as a separate matter.
It is worth knowing in advance about strong sedatives and antipsychotic medicines for agitation or aggression: in older people with dementia they raise the risk of stroke and of death, so they are prescribed only when safety is genuinely at stake, in short courses and with medical supervision. The cause of the behaviour is always looked for first — pain, infection, fear, noise, darkness, a full bladder. And one last thing: the person doing the caring needs help and respite too, and raising that with a doctor is entirely normal.
Online consultation
A remote conversation suits the first step well, when it is unclear whether a sign is worrying or simply part of ageing, and where to begin at all. The doctor will ask what exactly has changed and in what order, whether the decline came in steps, how walking, mood and bladder are doing, what heart and vascular conditions there are, and what medicines are being taken. It is worth preparing: a fortnight of blood pressure readings, recent test results, the full list of medicines and, if possible, the presence of somebody who sees the situation from outside.
By the end it is usually clear which investigation is needed first, which specialist to book with and which vascular factor is furthest out of control. Everyday questions are also convenient to sort out remotely: how to measure blood pressure at home, what to do about mood swings, how to adapt the flat. The limits are clear too: dementia cannot be diagnosed at a distance, that needs examination, testing and a scan. And if the face droops suddenly, an arm goes weak or speech fails, do not wait for any consultation — that is an ambulance.
This material is for information only and does not replace medical advice.
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