Vascular Cognitive Impairment (Vci)

Essentials

• Vascular cognitive impairment (VCI) encompasses all types of cognitive symptoms caused by circulatory disturbances, irrespective of the exact mechanisms.
• Information processing symptoms may manifest as narrow disturbances in one or more areas of cognitive function, or they may be progressive, extensive states that lead to severe memory disorder (old term: vascular dementia).
• The key causes of VCI are small vessel disease (SVD) and large vessel disease (LVD). Other types include states caused by cerebral haemorrhages, hypoperfusion and hereditary causes.
• The VCI group also contains mixed aetiologies where, in addition to a degenerative brain disease (most commonly Alzheimer's disease), also a clinically significant cerebrovascular disease has a role.

Epidemiology and risk factors

• Symptoms involving memory, executive functioning, as well as functions involving perception and speech are common after strokes due to cerebral infarction or haemorrhage. Following a cerebrovascular disorder, impairment of cognitive functions occurs in at least half of all patients. In studies on the Finnish population, 41% of working-age patients and even up to 71% of elderly patients with cerebral infarction have been found to have clinically significant impairment of at least one area of cognitive function, despite otherwise good neurological recovery.
• After stroke, extensive and severe impairment of information processing, dementia, occurs in 25% of elderly patients.
• Also brain infarcts and white matter changes with ostensibly no clinical symptoms, are associated with an increased risk of a memory disorder.
• In 15-20% of cases, progressive memory disorder is caused solely by a CVD, and in about 70% of these by small vessel disease. Mixed aetiologies are common especially in the eldest age groups, and in those, the impact of vascular factors on the progression of symptom picture is strong.
• The classic risk factors (hypertension, high cholesterol concentration, diabetes, obesity, sedentary life style, smoking) of cardiovascular disease and CVD in middle-age are associated with an increased risk of memory disorder in more advanced age. Low educational level has also been found to increase the risk of memory disorders.
• Extensive brain lesions caused by small vessel disease involve an increased risk of impaired information processing, dementia, depression, walking difficulty, falls, urinary tract symptoms, strokes, institutionalization, and death.

Symptoms and findings

Treatment

• The management of a memory disorder related to CVD concentrates on the causes and risk factors of CVD and on the treatment of other coexisting diseases, such as hypertension, hypercholesterolaemia and diabetes.
• Preventive measures are very important, and patients should be encouraged to change their lifestyle early enough: no smoking, weight management, as well as sufficient exercise and sleep.
• The benefit from physical exercise is based on its favourable effect on the management of CVD risk factors, and exercise also has a favourable effect on the brain-derived nerve growth factor.
• Before old age, the risk of memory disorders can be reduced by treating hypertension. Too low blood pressure should be avoided in elderly people and those with extensive white matter changes.
• Medication to prevent new circulatory disturbances should be prescribed according to stroke treatment guidelines. Clinical studies have not shown any differences in the effects of specific drugs (acetylsalicylic acid, dipyridamole, clopidogrel or anticoagulant therapy) in the symptomatic treatment of VCI.
• In VCI, medication indicated for memory disorders (galantamine Galantamine for Vascular Cognitive Impairment, donepezil Donepezil for Vascular Cognitive Impairment, memantine Memantine for Vascular Dementia, rivastigmine Rivastigmine for Vascular Cognitive Impairment) may be of benefit as far as cognition is concerned but not to improve functional independence.
• VCI or vascular dementia is not an official indication for any pharmaceutical ingredient that has been studied in Europe (EMA) or in the United States (FDA).
• Active lifestyle with versatile stimuli promote the maintaining of functional capacity.

Alzheimer's disease and CVD

• AD and CVD share many risk factors: hypertension, hypercholesterolaemia, diabetes and arterial diseases.
• Mixed AD + CVD is a significant subtype of progressive memory disease particularly in older age groups; at least half of patients over 80 with memory disorder have this subtype. Mixed memory disorder may turn out to be the most common single type of memory disorder.
• Clinical diagnosis is difficult as the patients will have focal neurological symptoms and findings suggestive of CVD and simultaneously changes on cerebral imaging due to both CVD and AD.
• Factors supporting the diagnosis of concurrent AD include a syndrome with predominantly early impairment of episodic memory, atrophy of the medial temporal lobe on MRI, as well as a decreased concentration of beta-amyloid 42 (Ab42) in CSF.
• Patients with AD and coexisting CVD may benefit from AD memory medication.
• Galanthamine is at least as effective here as in the treatment of AD alone. For donepezil, rivastigmine and memantine, there is no equivalent research evidence available.