Clinical presentation and mental status
Patients with vascular dementia often appear physically aged and helpless. Somatic status reveals concomitant pathologies: dyspnea, headaches, dizziness, as well as combined lesions of the heart, kidneys, and extremities. Patients are frequently accompanied by relatives during medical visits. Communication may be hindered due to age-related hearing loss (hypacusis) and memory impairment (hypomnesia).
Hallucinatory syndrome deserves special attention:
- Nature of visions: patients experience visual hallucinations (for example, seeing "little people"), but are unable to clearly discern them due to concomitant visual impairment.
- Triggers: episodes recur regularly (3–4 times a week) and are often provoked by weather sensitivity—changes in weather or inclement conditions.
- Dynamics of insight: insight is absent during the onset of hallucinations. The patient may try to point out the visions to their spouse and is genuinely surprised that she does not notice them. However, critical thinking is fully restored by morning. The patient evaluates the nocturnal episode as an "illusion," understands that "something is wrong with the head," and requests pharmacological treatment to relieve the symptoms.
Diagnosis of circulatory disorders
The diagnosis of Dementia vascularis is established based on a specific clinical picture and a carefully taken history confirming the presence of vascular pathology.
The following methods are used to objectively confirm cerebrovascular disorders:
- Ophthalmoscopy (ophthalmological examination): allows detection of retinal angiopathy. Fundus examination reveals sclerosis, characteristic tortuosity, and narrowing of the blood vessels.
- Instrumental studies:
- Rheoencephalography (REG).
- Head and neck vessel duplex ultrasonography.
Differential diagnosis
This disease must be differentiated from a number of other pathological conditions:
- Atrophic brain diseases: require differentiation from vascular dementia at their initial stages.
- Brain tumors: are ruled out if electroencephalography (EEG) shows no signs of local (focal) brain structure lesions, and the patient lacks symptoms of intracranial hypertension (elevated intracranial pressure).
- Systemic diseases: if symptoms develop in young individuals, it is first necessary to exclude general rather than cerebral pathologies—diabetes mellitus, systemic connective tissue diseases (collagenoses), and other specific vascular disorders.
Distinction from Alzheimer's and Pick's diseases
The main differences between vascular pathology and primary degenerative dementias lie in the preservation of the core personality and the specific stepwise course.
| Sign | Alzheimer's disease | Pick's disease | Vascular dementia |
|---|---|---|---|
| Personality | Changes are initially subtle, then obvious | Clearly pronounced from the onset of the disease | Accentuation of traits, core is not destroyed |
| Insight | Formal, then lost | Completely absent | Preserved, patient compensates for the deficit |
| Memory | Progressive amnesia from the start | Not pronounced initially | Slow hypomnesia with anecphoria |
| Emotions | Euphoria, then apathy | Passivity, rudeness, disinhibition | Asthenia, emotional lability |
| Writing and calculation | Impaired immediately (omission of letters) | Preserved for a long time | Calculation impaired, handwriting changes, but without gross errors |
| Course | Steadily progressive | Rapid progression | Stepwise, "fluctuating" |
Motor and speech functions are worth noting separately. In non-stroke vascular dementia, speech and habitual motor skills (praxis) are not grossly impaired. However, in the event of an acute cerebrovascular accident, neurological symptoms, apraxia, and sometimes epileptic seizures occur abruptly, strictly corresponding to the lesion zone. Productive psychotic symptoms (including clouded consciousness) also arise acutely against the background of vascular disruptions.
Briefly: answers to topical questions
What groups of pharmacological agents are used for pathogenetic and symptomatic treatment of vascular dementia?
For the pharmacotherapy of vascular dementia, drug groups similar to those used in Alzheimer's disease are prescribed. The mainstay of treatment includes the following medications:
- Central acetylcholinesterase inhibitors — galantamine (8–16 mg/day), donepezil (2–4 mg/day), and rivastigmine (2–6 mg/day) are prescribed.
- Glutamate receptor blockers — memantine is used at a dosage of 10–20 mg/day.
What specific neuroimaging features are detected on brain MRI in vascular dementia?
Brain MRI in vascular dementia reveals structural changes and the consequences of prior strokes. Specific neuroimaging features include:
- White matter lesions — subcortical and periventricular leukoaraiosis (microangiopathic leukoencephalopathy).
- Lacunes — lacunar infarcts or post-infarction cysts (rounded lesions up to 10 mm in size).
- Gliosis-type changes — developing as consequences of strokes.
- Cerebral atrophy — combined reduction in brain tissue volume.
Class and exam questions
How to distinguish writing impairments in vascular dementia from those in Alzheimer's disease?
In vascular disease, handwriting changes and calculation becomes difficult, but the patient does not make gross spelling errors. In Alzheimer's disease, the ability to write is lost very early—the patient constantly repeats or omits letters.
Is the patient's personality destroyed in vascular dementia?
No, the core of the personality remains intact. There is merely an accentuation of pre-existing personality traits, unlike in Pick's disease, where the personality is disintegrated from the very beginning.
Are speech and praxis always impaired in patients with vascular dementia?
No. If the disease runs its course without strokes, speech and habitual skills (praxis) are not severely impaired. Pronounced disturbances occur only after an acute stroke and depend on the localization of the lesion in the brain.
What else to study on this topic
- Mechanisms of hypomnesia with anecphoria
- Amnestic aphasia and apraxia in Alzheimer's disease
- Symptoms of motor neuron lesion in Pick's disease (bulbar symptoms, fasciculations)
- Signs of intracranial hypertension and focal lesion on EEG
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Other topics in "Chapter 19. Organic, Exogenous, and Somatogenic Mental Disorders"
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