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07-SEPTEMBER-2008 03:17:44 - Multi-infarct dementia Multi-infarct dementia Classification and external resources ICD-10 F01.1 ICD-9 290.4 DiseasesDB 8393 eMedicine med/3150 neuro/227 MeSH D015161 Multi-infarct dementia, also known as vascular dementia, is the second most common form of dementia after Alzheimer disease AD in older adults.1 The term refers to a group of syndromes caused by different mechanisms all resulting in vascular lesions in the brain. Early detection and accurate diagnosis are important, as vascular dementia is at least partially preventable. The main subtypes of this disease described at the moment are: vascular mild cognitive impairment, multi-infarct dementia, vascular dementia due to a strategic single infarct affecting the thalamus, the anterior cerebral artery, the parietal lobes or the cingulate gyrus, vascular dementia due to hemorrhagic lesions, small vessel disease which includes vascular dementia due to lacunar lesions and Binswanger's disease, and mixed Alzheimer's and vascular dementia. Vascular lesions can be the result of diffuse cerebrovascular disease or focal lesions or a combination of both, which is what is observed in the majority of cases. Mixed dementia is diagnosed when patients have evidence of AD and cerebrovascular disease, either clinically or based on neuroimaging evidence of ischemic lesions. In fact vascular dementia and Alzheimer's disease often coexist, especially in older patients with dementia. arrows : lacunar infarcts arrows : lacunar infarcts Contents 1 Symptoms 2 Epidemiology 3 Mortality/Morbidity 4 Clinical presentation 5 Diagnosis 6 Etiology 7 Investigations 8 Treatment 9 References 10 See also 11 External links Symptoms The onset of multi-infarct dementia often goes unnoticed in the early stages, particularly if the strokes are minor. If the strokes are minor, symptoms caused by each stroke may include mild weakness in the limbs, slurred speech, dizziness and a slight impairment to the short-term memory, though these do not last for long. However, the cumulative effects of these strokes will eventually result in noticeable symptoms being displayed. These symptoms include: problems with recent memory wandering or getting lost in familiar places walking with rapid, shuffling steps disinhibition, including loss of bladder or bowel control emotional lability difficulty following instructions problems handling money Epidemiology Vascular dementia is the second most common cause of dementia in the United States and Europe in the elderly, but it is the most common form in some parts of Asia. The prevalence of the illness is 1.5% in Western countries and approximately 2.2% in Japan. It accounts for 50% of all dementias in Japan, 20% to 40% in Europe and 15% in Latin America. The incidence of dementia is 9 times higher in patients who have had a stroke than in controls. 25% percent of stroke patients develop new-onset dementia within 1 year of their stroke. The relative risk of incident dementia is 5.5% within 4 years of suffering a stroke. The prevalence of vascular dementia is higher in men than in women and it increases with age. Mortality/Morbidity The 5-year survival rate is 39% for patients with vascular dementia compared with 75% for age-matched controls. Vascular dementia is associated with a higher mortality than 'Alzheimer's', presumably because of the excess in cardiovascular risk factors. Clinical presentation Patients suffering from vascular dementia present with cognitive impairment, acutely or subacutely, after an acute cerebrovascular event. After the onset a stepwise progression is typical. However stepwise progression may not be observed in small vessel disease, Binswanger disease or vascular dementia due to small lacunar infarcts. In small vessel disease the incidence peaks between the 4th and the 7th decades of life and 80% will have a history of hypertension. Patients develop progressive cognitive, motor and behavioural signs and symptoms. A significant proportion of them also develop affective symptoms. These changes occur over a period of 5-10 years. If the frontal lobes are affected, which is often the case, patients may present as apathetic or abulic. This is often accompanied by problems with attention, orientation and urinary incontinence. As already stated, small vessel disease and focal lesions often overlap, so these two patterns may be evident in the same individual concurrently. Rare genetic disorders which result in vascular lesions in the brain have other patterns of presentation. As a rule of thumb they tend to present earlier in life and have a more aggressive course. Diagnosis Several specific diagnostic criteria can be used to diagnose vascular dementia,2 including the Diagnostic and Statistical Manual of Mental Disorders, Fourth ion DSM-IV criteria, the International Classification of Diseases, Tenth ion criteria, the National Institute of Neurological Disorders and Stroke- Association Internationale pour la Recherche et L'Enseignement en Neurosciences NINDS-AIREN criteria,3 the Alzheimer's Disease Diagnostic and Treatment Center criteria, and the Hachinski ischemic score.4 Lateralizing signs such as hemiparesis, bradykinesia, hyperreflexia, extensor plantar reflexes, ataxia, pseudobulbar palsy, and gait and swallowing difficulties may be observed. In terms of cognitive testing patients have patchy deficits. They tend to have better free recall and fewer recall intrusions compared with patients with Alzheimer's disease. As small vessel disease often affects the frontal lobes, apathy early in the disease is more suggestive of vascular dementia because it usually occurs in the later stages of 'Alzheimer's'. Consequently patients with vascular dementia perform worse than their Alzheimer's disease counterparts in frontal lobe tasks such as verbal fluency. They also tend to exhibit more perseverative behaviour. They may also present with general slowing of processing ability, difficulty shifting sets and impairment in abstract thinking. In the more severe patients or those patients affected by strategic infarcts in the Wernicke or Broca areas; dysarthrias, dysphasias and aphasias may be present. Etiology Risk factors for vascular dementia include hypertension, smoking, hypercholesterolemia, diabetes mellitus, and cardiovascular and cerebrovascular disease. Investigations The recommended investigations for cognitive impairment should be carried out, including a dementia screening blood test, chest X-Ray, CAT scan and EKG. The screening blood test should typically include full blood count, liver function tests, thyroid function tests, lipid profile, erythrocyte sedimentation rate, C reactive protein, syphilis serology, calcium serum level, fasting glucose, urea and electrolytes, vitamin B-12, folate. In selected patients HIV serology and autoantibody testing may be done. Treatment The aim of the management is the prevention of further cerebrovascular lesions. This includes administering antiplatelet drugs and controlling major vascular risk factors hypertension, hypercholesterolemia, smoking and diabetes mellitus to mention a few. The general management of dementia includes referral to community services, judgment and decision-making regarding legal and ethical issues eg, driving, capacity, advance directives, and consideration of caregiver stress. Cholinesterase inhibitors such as galantamine have shown to be helpful in various randomised controlled trials, however their use is not licensed yet for this indication. Behavioral and affective symptoms are particularly important in this patient group and deserve special consideration. These problems if they develop tend to be resistant to conventional psychopharmacological treatment and in many cases lead to hospital admission and placement in permanent care. Agents that may be useful include antidepressants, neuroleptics and mood-stabilizers. Electroconvulsive therapy may be indicated in extreme cases provided a medical contraindication does not exist. References December 2007 ^ Multi-Infarct Dementia Fact Sheet. ^ Wetterling T, Kanitz RD, Borgis KJ January 1996. Comparison of different diagnostic criteria for vascular dementia ADDTC, DSM-IV, ICD-10, NINDS-AIREN. Stroke 27 1: 30-6. PMID 8553399. ^ Tang W, Chan S, Chiu H, Ungvari G, Wong K, Kwok T, Mok V, Wong K, Richards P, Ahuja A 2004. Impact of applying NINDS-AIREN criteria of probable vascular dementia to clinical and radiological characteristics of a stroke cohort with dementia. Cerebrovasc. Dis. 18 2: 98-103. doi:10.1159/000079256. PMID 15218273. ^ Pantoni L, Inzitari D 1993. Hachinski's ischemic score and the diagnosis of vascular dementia: a review. Italian journal of neurological sciences 14 7: 539-46. doi:10.1007/BF02339212. PMID 8282525. See also Cerebrovascular accident Binswanger's disease External links Helpguide article on vascular dementia J Bowler V Hachinsky, Vascular Cognitive Impairment: Preventable Dementia, Oxford University Press 2003, ISBN 0-19-263267-1. Multi-Infarct Dementia Fact Sheet at nia.nih.gov Multi-Infarct Dementia at nmha.org Vascular Dementia: Symptoms, Prognosis, and Support at helpguide.org American Academy of Neurology 2007, December 21. Walking And Moderate Exercise Help Prevent Dementia. ScienceDaily. Retrieved December 21, 2007, from http://www.sciencedaily.com/releases/2007/12/071219202948.htm Preventing Vascular Dementia at dementiaguide.com v d e WHO ICD-10 mental and behavioral disorders F · 290-319 Neurological/symptomatic Dementia Alzheimer's disease, multi-infarct dementia, Pick's disease, Creutzfeldt-Jakob disease, Huntington's disease, Parkinson's disease, AIDS dementia complex, Frontotemporal dementia, Elopement, Sundowning, Wandering · Delirium · Post-concussion syndrome · Organic brain syndrome Psychoactive substance alcohol drunkenness, alcohol dependence, alcoholic hallucinosis, Alcohol withdrawal, delirium tremens, Korsakoff's syndrome, alcohol abuse · opioids opioid dependency · sedative/hypnotic benzodiazepine withdrawal · cocaine cocaine dependence · general Intoxication, Drug abuse, Physical dependence, Withdrawal Psychotic disorder Schizophrenia disorganized schizophrenia · Schizophreniform disorder · Schizotypal personality disorder · Delusional disorder · Folie à deux · Schizoaffective disorder Mood affective Mania · Bipolar disorder · Clinical depression · Cyclothymia · Dysthymia Neurotic, stress-related and somatoform Anxiety disorder Agoraphobia, Panic disorder, Panic attack, Generalized anxiety disorder, Social anxiety, Social phobia · OCD · Acute stress reaction · PTSD · Adjustment disorder · Conversion disorder Ganser syndrome · Somatoform disorder Somatization disorder, Body dysmorphic disorder, Hypochondriasis, Nosophobia, Da Costa's syndrome, Psychalgia · Neurasthenia Physiological/physical behavioral Eating disorder: Anorexia nervosa · Bulimia nervosa Sleep disorder: Dyssomnia Hypersomnia, Insomnia · Parasomnia REM behavior disorder, Night terror · Nightmare Sexual dysfunction: Erectile dysfunction · Premature ejaculation · Vaginismus · Dyspareunia · Hypersexuality · Female sexual arousal disorder Postpartum depression · Postnatal psychosis Adult personality and behavior Personality disorder · Passive-aggressive behavior · Kleptomania · Trichotillomania · Voyeurism · Factitious disorder · Munchausen syndrome · Ego-dystonic sexual orientation · Fetishism Mental retardation Mental retardation Psychological development developmental disorder Specific: speech and language expressive language disorder, aphasia, expressive aphasia, receptive aphasia, Landau-Kleffner syndrome, lisp · Scholastic skills dyslexia, dysgraphia, Gerstmann syndrome · Motor function developmental dyspraxia Pervasive: Autism · Rett syndrome · Asperger syndrome Behavioral and emotional, childhood and adolescence onset ADHD · Conduct disorder · Oppositional defiant disorder · Separation anxiety disorder · Selective mutism · Reactive attachment disorder · Tic disorder · Tourette syndrome · Speech stuttering · cluttering Retrieved from http://en..org/wiki/Multi-infarct_dementia Categories: Neurological disorders | Psychiatry | Cognitive disordersHidden category: Articles needing additional references from December 2007 Views Article Discussion this page History Personal tools Log in / create account Navigation Main page Contents Featured content Current events Random article Search Go Search Interaction Community portal Recent changes Contact Donate to Help Toolbox What links here Related changes Upload file Special pages Printable version Permanent link Cite this page Languages Español Italiano Suomi Français Nederlands 中文 This page was last modified on 20 August 2008, at 21:11
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