Vascular dementia

Expert reviewer Rahul Bhattacharya, Consultant Psychiatrist
Next review due August 2022

Vascular dementia happens when there is a problem with the supply of blood to the brain. It is the second most common type of dementia, which is a term used to describe a set of symptoms that include problems with memory and thinking. Vascular dementia sometimes happens after a stroke or a series of ‘mini-strokes’.

About vascular dementia

Blood is delivered to the brain through a series of vessels – this is known as the vascular system. If these vessels become damaged (if they leak or are blocked) then blood cannot reach the brain cells and eventually these cells will die. This can happen after a stroke. It may also happen following a series of ‘mini-strokes’, some of which may not be obvious to the person affected.

Vascular dementia accounts for around one in six cases of dementia. The biggest risk factor is age: people between 60 and 70 are most likely to be affected. Other common risk factors for stroke are also important, including smoking, being very overweight and having high blood pressure. Unlike the most common type of dementia, Alzheimer’s disease, vascular dementia is more common in men than in women.

Symptoms of vascular dementia can come on more suddenly than with other types of dementia and may show up after a stroke. People may have personality changes before developing other symptoms more commonly linked to dementia, such as loss of memory and confusion. Depression and anxiety are also common.

Vascular dementia does get worse over time. But because it is often caused by a series of small strokes, deterioration tends to happen in steps, rather than gradually. There are usually periods in between when the condition is stable.

Symptoms of vascular dementia

Vascular dementia symptoms differ from person to person. The symptoms depend on which part of the brain is affected by the lack of blood supply that causes vascular dementia. The doctor will look for specific symptoms that may show that a particular part of the brain has been affected.

The symptoms of vascular dementia can include:

• problems with sight, such as loss of an area of vision in one or both eyes
• difficulty speaking
• paralysis in part of the body, for example on one side only
• movement disorders, such as tremors, muscle spasms, involuntary movements or not being able to keep still

Other signs of vascular dementia may include:

• difficulty solving problems or taking in information
• loss of inhibitions (people may speak or behave inappropriately)
• loss of interest and enthusiasm
• poor concentration and difficulty focusing
• depression and anxiety
• memory loss
• emotional symptoms, such as becoming easily upset or angry
• fits (seizures)
• unsteadiness and tendency to fall
• loss of bladder control (incontinence)

How vascular dementia develops

Unlike other forms of dementia, vascular dementia can come on suddenly. This is one of the main differences between vascular dementia and Alzheimer's disease, for example. Vascular dementia often follows a stroke or series of ‘mini-strokes’. In fact, dementia that starts within three months of having a stroke is a strong indication to a doctor that dementia may be vascular.

As with other types of dementia, vascular dementia is a progressive condition and will worsen over time. The dementia symptoms tend to get worse in ‘steps’, with periods in between when it is quite stable. Generally, vascular dementia tends to have a shorter course than Alzheimer’s disease. On average someone lives for around five years after diagnosis, but this does vary a great deal between people.

You may have heard about different stages of dementia. However, this isn’t very useful in managing or treating vascular dementia. There are a few different staging systems, but they were really developed for use in Alzheimer’s disease research, to compare clinical trial results more easily.

Early stages

The first sign of vascular dementia may be personality changes. Often, this is noticed by people closest to the person with vascular dementia. It is quite common after a major stroke for someone’s emotions to be triggered more easily and this can be a sign of damage to particular parts of the brain.

Another difference between vascular dementia and Alzheimer's disease is that memory problems are often the first sign of Alzheimer’s. In vascular dementia, problems with memory and reasoning usually come on later, as the condition worsens. Generally, thinking, planning and concentrating are more affected than memory.

Longer term

Over time, people with vascular dementia may become slower and confused. About one in 10 people develop fits.

Depression is common in people with vascular dementia, affecting between two and five out of every 10 people. This can be because people with vascular dementia have greater and longer-lasting insight into their condition than with other types of dementia. They may realise that they have dementia symptoms.

Around two out of every 10 people diagnosed with vascular dementia become agitated or aggressive at times, although doctors don’t fully understand why this is. Falls may be more likely, particularly in people who have become unsteady when walking. In the later stages, around one in five people with vascular dementia can become agitated and even aggressive at times, which can be upsetting for those close to them.

As with other types of dementia, people with vascular dementia will have increasing difficulty living independently and will need more help over time. They may eventually need looking after in residential care.

If you’re caring for someone with vascular dementia, it’s important to recognise that this can be very stressful and look after yourself as a dementia carer too. You may need help at home and periods of respite care, particularly if your relative is disabled after having a stroke as well as having vascular dementia.

Causes of vascular dementia

Unlike other types of dementia, doctors fully understand the cause of vascular dementia. Parts of the brain become damaged because there is a problem with the blood supply. This lack of blood supply causes vascular dementia symptoms. Blood brings oxygen and nutrients to all parts of the body, including the brain. So if there is no ready flow of blood to brain cells, they will not be able to work properly and will eventually die.

There are several sub-types of vascular dementia.

• The damage that causes vascular dementia may be due to a large stroke.
• It could also be caused by a series of ‘mini-strokes’. These are known as infarcts, so this specific type of dementia is ‘multi-infarct dementia’.
• It may be due to small arteries ‘furring up’ (known as atherosclerosis or arteriosclerosis) in a similar way to the blocking of the coronary arteries in a heart attack.
• A bleed in the brain (haemorrhage) will also interrupt the blood supply. A bleed may be small or large. Small bleeds causing vascular dementia may be due to protein deposits collecting on the walls of small arteries and weakening them. These are deposits of a protein called beta-amyloid, which is also associated with Alzheimer’s disease.
• There is a rarer type of dementia called ‘subcortical vascular dementia’, affecting small blood vessels deep in the brain. Here, the progression of dementia symptoms may be more gradual.

High blood pressure is a risk factor for several of these sub-types, including large strokes, mini-strokes, large bleeds in the brain and furred arteries (arteriosclerosis).

Diabetes can cause damage to small and large blood vessels and can be a contributing cause of vascular dementia.

It isn’t unusual for people with vascular dementia to have Alzheimer’s disease as well. This combination of vascular dementia and Alzheimer's disease is called mixed dementia.

In rare cases, vascular dementia can be caused by a gene passed on in your family. When this does happen, it’s mostly the result of an inherited condition called CADASIL, which affects people at a younger age.

Treatments for vascular dementia

There is sadly no cure for vascular dementia, and there are no medicines that can specifically treat its symptoms. But there are medicines that can slow down the development of vascular dementia, and other therapies that can improve life for people affected. For someone who has had a stroke, treatment will also include physical rehabilitation.

Medicines to slow down vascular dementia

Treatment of vascular dementia involves treating the underlying causes, which will help to slow down its development. This means that the medicines the doctor prescribes will vary, depending on other medical conditions. They may suggest anti-hypertensives to treat high blood pressure, for example. If you have diabetes, your doctor will also want to make sure that it is well controlled.

Some doctors prescribe a small dose of aspirin a day if vascular dementia is caused by strokes. This may help to slow down the development of more serious vascular dementia symptoms by preventing further strokes. Some people can’t take aspirin, if they’ve had a stomach ulcer, for example. Another medicine that may be used to prevent stroke is called clopidogrel.

For people with mixed dementia, doctors may prescribe one of the medicines available for Alzheimer’s disease. But these have not been shown to work in vascular dementia and are not recommended for use outside clinical trials.

Medicines to manage other difficulties

As depression is common in vascular dementia, the doctor may prescribe a course of anti-depressants. Depending on how well the person is able to communicate and understand, doctors may suggest talking therapies as a way to help them emotionally.

People with vascular dementia can sometimes have episodes of aggression and agitation. There are medicines available that can calm people down, but these may make symptoms of vascular dementia worse, or increase the risk of stroke. So doctors will only use them for a short time if other ways of trying to calm the situation have failed.

Other therapies for vascular dementia

There are several other ways that life can be improved for people with vascular dementia and their families. Physiotherapy and occupational therapy can help to keep the person with dementia mobile and avoid falls. People who are unsettled, agitated or depressed may find complementary therapies such as aromatherapy or massage soothing. Exercise and activity-based therapies may also be helpful, including music therapy or dance.

Support for carers

For carers, understanding how the condition is likely to affect the person with the dementia can make it easier to prevent problems and cope with them when they arise. Caring for someone with dementia can be particularly demanding and stressful so it’s important that carers are encouraged to look after themselves.