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Diagnosis and Management of Vascular Dementia

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good morning my name is dr. Steven Chen,I may use geriatric psychiatrist here at,UCLA and the topic I’m going to present,today is on vascular dementia so for,those of you who may have participated,in our webinars before and and to those,who are joining us new you can post,questions you can ask questions using,Twitter or or commenting on facebook,using the hashtag UCLA and D chat if,you’re on Twitter okay so what is,vascular dementia I I sort of designed,this talk for family for caregivers for,people who live who work at facilities,who might care for some of these,patients so what is vascular dementia,I’ll start first by talking about what,vascular dementia is not it’s unlike,Alzheimer’s disease unlike,frontotemporal dementia or Lewy body,dementia,the problem with vascular dementia is,not in the brain it’s not with those,other types of dementias,the problem is within the brain cells or,between the brain cells with faster,dementia the problem actually starts,with the blood vessels that that supply,the brain with blood and oxygen so,usually there’s the the types of,vascular problems or blood supply,problems in vascular dementia are what,we call ischemia or inadequate blood due,to narrowing of the arteries or,sometimes there can be a bleed that,causes disruption of blood supply to the,oxygen and that leads to death of or our,injury of brain cells,causing dysfunction of those particular,that particular part of the brain so you,can have either large single strokes,that can affect brain function you can,also have what we call micro vascular,injuries or a diseased small where small,vessels are involved and small parts of,the brain are damaged over a longer,period of time and they may not be,noticeable they may not manifest as what,you might expect from a stroke it may be,a very very subtle or what we call,subclinical type of injury they don’t,really have any clinical symptoms,associated with that until they,accumulate gradually over time so so,this problem with the vascular or blood,supply to the brain can sometimes lead,to dementia and that’s where we have,cases of vascular dementia and what is,dementia some of you may have,participated in some of our other,webinar series webinars in this series,know that the dementia is defined as an,impairment in memory or other cognitive,functions as well as impairment in one’s,functioning so not only do they have,memory impairment or problems with word,finding or maybe finding their way,around or disorientation but also with,problems with daily activities so,problems with say managing finances or,driving or running errands that’s what,we mean by functional impairment what,are some of the common clinical features,of vascular dementia usually there’s,some abrupt onset and symptoms so,there’s the patient is doing fine they,seem normal and then there’s an abrupt,change in their ability to remember,or ability to think and then over time,there can be a stepwise decline as you,as the patient experiences either small,or large vascular events or even strokes,and this commonly can affect one’s gait,or ability to walk it can affect other,motor abilities such as fine motor you,know motor coordination it can also,affect one’s ability to control bladder,or bowel so that can lead to,incontinence and then it can also affect,one’s mood the patient might seem a,little bit more have a little bit more,uncontrolled trouble controlling their,mood or their affect so they might,actually you know laugh or cry,inappropriately or at for no apparent,reason how common is vascular dementia,well in the United States vascular,dementia represents the second most,common type of dementia Alzheimer’s,disease is by far the most common type,of dementia comprising a but roughly,two-thirds of cases but vascular,dementia comes second representing,somewhere between ten and twenty percent,of all cases of dementia and amongst the,elderly seventy plus your year old,people about 4.2 percent have vascular,dementia vascular dementia is more,common in men than in women it’s also,more common in African Americans as well,as Asians suggesting there may be some,genetic component to to the risk but,there may also be some associated,lifestyle factors as well we know that,so in Japan vascular dementia is,actually the most common type of,dementia we may,we think that maybe diet is is an,important factor interestingly Hawaiians,who are of Japanese descent so they,maybe they have they share some of the,genes with their Japanese relatives but,they also have a different diet a,different lifestyle their risk for,vascular dementia is actually somewhere,in between people who are Japanese,living in Japan and people who are not,Japanese living in the u.s. so I’d like,to compare vascular dementia to,Alzheimer’s disease to sort of give a,sense as to how these two are different,so with faster dementia as as I said in,the first slide are caused by strokes,both large and small that lead to to,damage or dysfunction of parts of the,brain and whereas in Alzheimer’s disease,it’s related to problems with the brain,cells and also the the actual brain,tissue parts of the brain that lie,between cells the onset of vascular,dementia is usually abrupt whereas with,Alzheimer’s it’s more insidious and and,maybe it just kind of creeps up on you,and then over time with vascular,dementia you might see a stepwise,decline as opposed to Alzheimer’s,disease it is more of a gradual,progressive course both vaster dementia,and Alzheimer’s patients will experience,memory loss however they may be at the,earlier stages there may be some,distinction in the type of memory loss,and Alzheimer’s patients tend to be more,amnestics so they’ll have trouble,remembering words or remembering events,even if you give them clues or hints,embassador dementia they are able to,store the memory or in,code the memory they just have,difficulty recalling the memory or,retrieving the memory so if you in a,typical test in the office we might give,them three words to remember and the,people with vascular dementia won’t will,have difficulty remembering the words,but if you give them clues they will,often be able to then retrieve that,those words both types of dementia can,are associated with psychiatric symptoms,including depression and apathy anxiety,agitation one distinction between,vascular dementia and Alzheimer’s is,that depression tends to be more common,and vascular dementia,whereas in Alzheimer’s disease apathy or,a lack of motivation or interest is is,more more common this slide shows a,comparison of MRIs of a patient with,vascular dementia and a patient with,Alzheimer’s disease and so the the,distinctions that I’d like to point out,are highlighted by the arrows so for,vascular dementia the red arrows are,pointing to the the white parts of the,brain these are changes this is what,happens to brain tissue when there has,been some disruption of vascular supply,so this is what this is what strokes,would look like over time on MRI whereas,the on the bottom set of slides a,patient with Alzheimer’s disease the,yellow arrows point to the spaces the,black spaces in between the what we call,gyri of the brain so in between brain,and that’s cerebrospinal fluid so that,has really no you know that’s,what fills up the brain when there’s,loss of brain tissue and in Alzheimer’s,disease there is a trophy or a shrinking,of brain tissue and so what fills that,up is is CSF which is in black so you,see I’m sorry I don’t have a comparison,to a normal patient or a patient without,Alzheimer’s disease but what what the,arrows illustrate are a enlargement of,CSF space so the first one are an,enlargement of what we call sulci and,then the the next slide is in the next,two slides are enlargement of ventricles,that contain cerebrospinal fluid makes,dementia so what do we mean by mixed,dementia it basically means a,combination of vascular dementia and,Alzheimer’s disease many people with,vascular dementia will also have,Alzheimer’s disease so on this Venn,diagram to the right illustrates first,of all the the larger proportion of,patients who have Alzheimer’s disease,and there’s an overlap with some portion,of vascular dementia patients who have,both and that is what we refer to as a,mixed dementia vascular dementia and,Alzheimer’s disease though they do have,distinctions they also share some,similar risk factors age is the largest,risk factor for both the presence of,hypertension and diabetes as well as,obesity are also shared risk factors for,both Alzheimer’s disease and vascular,dementia and then the final point on the,slide is this to show that the someone,with who has Alzheimer’s disease,the course of their illness can very,much be affected by the presence of,vascular disease so in the red you see,what a typical course of someone with,only vascular dementia might be it’s a,sort of a stepwise decline in the dark,blue is an illustration or a schematic,of how a typical course Alzheimer’s,disease might progress just gradually,and progressively and then someone with,mixed dementia you’ll see will progress,gradually at some points and then have,some stepwise decline in between which,results in a overall more rapid,progression of their dementia and then,you can have someone with very clean,Alzheimer’s disease without any vascular,disease that would progress more slowly,so again the the progression of,Alzheimer’s can either be accelerated or,slowed down depending on how much,vascular disease there is what can we do,about vascular dementia well first of,all the bad news there is no cure and,there is no fda-approved medication to,treat faster dementia however more so,than the other types of dementia is,faster dementia is preventable and we do,this by trying to control risk factors,for stroke if one has elevated blood,pressure or cholesterol or diabetes man,optimal management of those conditions,should reduce the risk for developing,vascular dementia also evaluation for,heart disease is also very important,because our,any certain types of heart disease can,increase risk for developing clots and,those clots can travel from the heart to,the brain and cause a stroke so it’s,very important also not only to look at,overall vascular health but also,cardiovascular health or issues related,to keeping the heart healthy there are,data that suggests that cholinesterase,inhibitors which include an episode or,aricept rivastigmine or exelon as well,as memantine or namenda there there are,data that suggest that these agents are,effective in at least temporarily,improving memory or thinking and in,patients with vascular dementia we may,not be able to cure or necessarily treat,and effectively treat vascular dementia,but it is important to try to treat the,psychiatric symptoms that may emerge,over the course of the illness again a,couple slides ago I mentioned depression,is quite common and vaster dementia so,if the patient develops depression on,top of vascular dementia it should be,treated with typically with,antidepressants though at this point,there are not very good studies that,show that treating patients with,vascular dementia and depression are,effective but I think they are worth,worth prescribing and finally just like,with all the other types of dementia,that affect the patient’s functioning,it’s important to and it’s important to,provide support not only for the patient,but also for the caregiver and to have a,good evaluation of the environment,some of the behavioral disturbances or,psychiatric symptoms that are associated,with all the dimensions are often the,most challenging aspect of managing,these illnesses and they don’t respond,very well to some of our medications,they do respond to modifying the,environment so that the patient and the,caregiver are well supported that the,patient has what they need in their,everyday lives to do not become agitated,or upset or depressed so things like,making sure that they have the,appropriate stimulation at home or in,the facility making sure that all of,their needs are met basic things like,hunger and thirst and going to the,bathroom,so just like with all the other,dimensions the management of vascular,dementia is no different in terms of,support for the patient and the,caregiver and the environment so this,concludes my presentation again a,reminder if you’d like to ask questions,please use the hashtag UCLA MD chat on,Twitter or our comment on our Facebook,page,so I’ll just take a look at some of the,questions that have been fed through,sorry they’re quite of okay so first,question are there any lifestyle factors,that might help prevent faster dementia,yes we think so,and they are the same factors as what we,think might prevent or at least slow,down the progression of Alzheimer’s,disease and those things are,common-sense things like daily exercise,a healthy diet ones one that includes,multiple servings of fruits and,vegetables each day staying active both,mentally and socially in addition to,physical exercise second question what,type of doctors should I consult with if,I think my loved one has vascular,dementia well I’m a geriatric,psychiatrist I certainly sealed a number,of patients who have vascular and mixed,dementia so one option is to see a,geriatric psychiatrist I know not not,all parts of the country have have,access to geriatric psychiatrists a,psychiatrist an adult psychiatrist who,may have experience with with the,geriatric population who maybe visits,skilled nursing facilities or assisted,living facilities where this is a very,common problem may also be a good idea,geriatric medicine doctors these are,doctors who are internists but also have,received specialty training and,geriatric medicine they are also seeing,a lot of these patients and and may have,some good ideas about,management and an evaluation also,neurologists these are doctors who,specialize who are trained and all sorts,of brain illnesses including Alzheimer’s,and vascular dementia so they would be,another very good resource if you have,if you know of someone who might have a,vascular dementia okay,it looks like those are all the,questions that we have so I want to,thank you very much for participating in,today’s webinar and if you have,additional questions you can certainly,continue to later on you can certainly,continue to tweet them or or add them to,comments on our Facebook page thank you,very much

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