Vascular dementia may be the most common form of dementia in the elderly

doi:10.1016/S0022-510X(02)00252-6

Journal of the Neurological Sciences

Volumes 203–204, 15 November 2002, Pages 7-10

https://doi.org/10.1016/S0022-510X(02)00252-6 Get rights and content

Abstract

Cerebrovascular lesions, mainly lacunes and white matter ischemia, are common in elderly patients with dementia. Vascular dementia (VaD) is the second most common cause of dementia, after Alzheimer's disease (AD). However, lacunar strokes have become an important factor in the clinical expression of AD. Also, population-based studies indicate that vascular risk factors increase the risk of developing AD. It is postulated here that the two main causes of VaD—stroke and ischemic heart disease (IHD)—may be responsible for the majority of cases of dementia in the elderly.

Stroke-related VaD: Cerebrovascular disease (CVD) is the second leading cause of death worldwide. About 1/3 of stroke survivors [range: 25–41%] 65 years old and above develop VaD within 3 months following the ictus. In the USA alone, 125,000 new cases/year of VaD occur after ischemic stroke (about 1/3 of the 360,000 incident cases of AD). Therefore, more than 1 million elderly people are currently affected by poststroke VaD in the USA. Since current criteria identify “pure” cases of AD and VaD, it is likely that “AD plus CVD” (“mixed” dementia) could be responsible for a large number of cases currently diagnosed as probable AD.

Cardiogenic VaD: By 2020, IHD leading to congestive heart failure (CHF) will become the leading cause of disability worldwide. Vascular cognitive impairment occurs in 26% of patients discharged from hospitals after treatment for CHF. Cognitive dysfunction correlates with left ventricular dysfunction and systolic blood pressure below 130 mm Hg. CHF is a leading cause of hospital admissions in Western nations (4.5 million cases in the USA alone) and is a growing problem in developing countries. Furthermore, over 800,000 patients/year undergo coronary artery bypass graft (CABG) surgery worldwide, including 300,000 patients in the USA. Measurable cognitive dysfunction occurs post-CABG in 80–90% of patients at hospital discharge. Long-term (5 years) incidence of cognitive defects is 42%. Finally, an international study found short-term postoperative cognitive dysfunction in 26% of patients (>60 years) after abdominal or orthopedic surgery; most of them may be instances of VaD.

In conclusion, VaD may be the most underdiagnosed and undertreated form of dementia in the elderly.

Introduction

Vascular dementia (VaD) remains the second most common form of dementia in the elderly after Alzheimer's disease (AD) [1], [2]. Furthermore, numerous vascular factors appear to be of major importance in the pathogenesis and clinical expression of AD [3]. The high prevalence of VaD in the aging population is a reflection of the fact that stroke and ischemic heart disease (IHD) are the two leading causes of morbidity and mortality in the elderly. It is well known that the incidence of stroke rises exponentially with age [4], increasing 100-fold from age 30–40 [3/10,000] to age 80–90 [300/10,000]. Likewise, the high prevalence of cerebrovascular and cardiovascular pathologies capable of producing VaD in the elderly is directly related to the progressive aging of the population [5]. In Europe and North America, the fastest growing segment of the population is older than 85 years and will number nearly 19 million by the year 2050. Not surprisingly, the World Health Organization predicts that coronary heart disease (CHD) will remain the leading cause of loss of productive years of life well into the current century.

Section snippets

Types of VaD

The main categories of VaD are due to small-vessel and large-vessel disease [6]. The latter results from repeated strokes leading to multi-infarct dementia (MID), or to a single strategic cortico-subcortical stroke affecting mainly anterior or posterior cerebral artery territories; small-vessel disease causes both lacunar strokes and Binswanger disease. The latter category includes both lacunar strokes and Binswanger disease due to incomplete ischemia of the periventricular white matter.

Cardiogenic dementia

In 1981, an editorial in The Lancet suggested the use of the name “cardiogenic dementia” for the condition observed in patients that presented cognitive deterioration following recurrent episodes of cardiac arrhythmias or heart disease [8].

In fact, the deleterious effects of cardiovascular disease on cognitive function in the aged are only beginning to be recognized. For instance, in a recent Italian study, Zuccalà et al. [9] demonstrated cognitive impairment in one out of four patients (26%)

Dementia post-coronary artery bypass graft (CABG) surgery

As a direct result of the high prevalence of coronary artery disease, during the past 35 years, coronary artery bypass graft (CABG) surgery has been the procedure most extensively performed using the cardiopulmonary bypass (CPB) machine. More than 800,000 patients undergo this procedure every year, including about 300,000 patients in the USA alone [22].

The CABG procedure is safe in most instances; the complications can be classified as postcardiotomy syndrome, hypotensive brain injury, and

Pathogenesis

Two main theories have been proposed to explain this elevated frequency of cognitive deficit: (1) hypoperfusion and (2) cerebral microembolism.

Postmortem studies in patients who underwent CABG surgery have demonstrated the frequent occurrence of ischemic neuronal damage and neuronal loss in the cerebral cortex, the cerebellar cortex, and the basal ganglia, along with watershed infarctions. It has been postulated that these lesions may result from the loss of cerebral autoregulation in the

Prevalence of vascular cognitive impairment

Newman et al. [31] studied the long-term (5-year incidence) cognitive effects of CABG surgery and found that close to half of the patients (42%) had significant long-term cognitive dysfunction, compared to 53% at hospital discharge.

It is possible that the role of cerebral hypoperfusion during major surgery remains important, since a comparison of stent placement versus CABG showed a significant decrease in neurological dysfunction following the stent procedure [32]. Moreover, the International

Conclusion

In summary, it is clear from the above data that vascular cognitive impairment of cardiac origin, resulting from CHF, cardiac arrhythmias, and post-CABG surgery, is a frequent and undiagnosed cause cognitive decline in the elderly. There is a need for prospective studies to clarify the pathogenesis of this condition and to provide appropriate measures for prevention and treatment of cardiogenic dementia and other forms of VaD.

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View full text

Vascular dementia may be the most common form of dementia in the elderly

Abstract

Introduction

Section snippets

Types of VaD

Cardiogenic dementia

Dementia post-coronary artery bypass graft (CABG) surgery

Pathogenesis

Prevalence of vascular cognitive impairment

Conclusion

Lancet

J. Stroke Cerebrovasc. Dis.

Int. J. Cardiol.

Ann. Thorac. Surg.

Ann. Thorac. Surg.

Chest

Lancet

The incidence of dementia: a meta-analysis

Neurology

The incidence of vascular dementia in Canada: a comparison with Europe and East Asia

Neuroepidemiology

Alzheimer disease as a vascular disorder: nosological evidence

Stroke

Vascular dementia today

Rev. Neurol. (Paris)

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

Neurology

Vascular dementia: a new beginning. Shifting focus from clinical phenotype to ischemic brain injury

Neurol. Clin.

Hypotension and cognitive impairment: selective association in patients with heart failure

Neurology

Low blood pressure and dementia in elderly people: the Kungsholmen project

Br. Med. J.