Vascular Dementia/ Multi-infarct Dementia Vascular dementia formerly known as Multi-Infarct Dementia refers to a subtle, progressive decline in memory

and cognitive functioning. It occurs when the blood supply carrying oxygen and nutrients to the brain is interrupted by a blocked or diseased vascular system. If blood supply is blocked for longer than a few seconds, brain cells can die, causing damage to the cortex of the brainthe area associated with learning, memory, and language. It is one of the most common forms of dementia, ranking only second to Alzheimers disease. Depending on the person, and the severity of the stroke or strokes, onset of vascular dementia may come abruptly with fluctuating, rapid changes in memory and other cognitive impairment.

Risk factors

Increasing age. Incidence increases with age.The disorder is rare before age 65, and risk rises substantially during 80s and 90s. History of heart attack, strokes or mini strokes. Heart attack increased the risk of having blood vessel problems in the brain. The brain damage that occurs with a stroke or a mini stroke (transient ischemic attack) may increase the risk of developing dementia. Atherosclerosis. This condition occurs when deposits of cholesterol and other substances (plaques) build up in arteries and narrow the blood vessels. Atherosclerosis can increase the risk of vascular dementia and possibly the risk of Alzheimer's disease by reducing the flow of blood that nourishes the brain. High cholesterol. Elevated levels of low-density lipoprotein (LDL), the so-called "bad" cholesterol, are associated with an increased risk of vascular dementia, and possibly with a higher risk of Alzheimer's disease. High blood pressure. High blood pressure, puts extra stress on blood vessels everywhere in the body, including the brain. This increases the risk of vascular problems in the brain. Diabetes. High glucose levels damage blood vessels throughout the body. Damage in brain blood vessels can increase the risk of stroke and vascular dementia. Smoking. Smoking directly damages your blood vessels, increasing the risk of atherosclerosis and other circulatory diseases, including vascular dementia. Atrial fibrillation. In this abnormal heart rhythm, the upper chambers of the heart begin to beat rapidly and irregularly, out of coordination with the heart's lower chambers. Atrial fibrillation increases the risk of stroke by leading to poor blood flow to the brain and elsewhere in the body.

Causes of vascular dementia Vascular dementia results from conditions that damage your brain's blood vessels, reducing their ability to supply your brain with the large amounts of nutrition and oxygen it needs to perform thought processes effectively.

Common conditions that may lead to vascular dementia include:

Stroke (infarction) blocking a brain artery. Strokes that block a brain artery usually cause a range of symptoms that may include vascular dementia. But some strokes don't cause any noticeable symptoms. These "silent brain infarctions" still increase dementia risk. With both silent and apparent strokes, the risk of vascular dementia increases with the number of infarctions that occur over time. One type of vascular dementia involving many strokes is called multi-infarct dementia. Narrowed or chronically damaged brain blood vessels. Conditions that narrow or inflict long-term damage on your brain blood vessels can also lead to vascular dementia. These conditions include the wear and tear associated with aging; high blood pressure; hardening of the arteries; diabetes; lupus erythematosus; brain hemorrhage; and temporal arteritis.

Signs and symptoms Vascular dementia affects different people in different ways and the speed of the progression varies from person to person. Some symptoms may be similar to those of other types of dementia and usually reflect increasing difficulty to perform everyday activities like eating, dressing, or shopping. Behavioral and physical symptoms can come on dramatically or very gradually, although it appears that a prolonged period of TIAsthe mini-strokes discussed aboveleads to a gradual decline in memory, whereas a bigger stroke can produce profound symptoms immediately. Regardless of the rate of appearance, vascular dementia typically progresses in a stepwise fashion, where lapses in memory and reasoning abilities are followed by periods of stability, only to give way to further decline. Common mental and emotional signs and symptoms Slowed thinking Memory problems; general forgetfulness Unusual mood changes (e.g. depression, irritability) Hallucinations and delusions Confusion, which may get worse at night Personality changes and loss of social skills

Common physical signs and symptoms of vascular dementia Dizziness Leg or arm weakness Tremors Moving with rapid, shuffling steps Balance problems Loss of bladder or bowel control Common behavioral signs and symptoms of vascular dementia Slurred speech

Language problems, such as difficulty finding the right words for things Getting lost in familiar surroundings Laughing or crying inappropriately Difficulty planning, organizing, or following instructions Difficulty doing things that used to come easily (e.g. paying bills or playing a favorite card game) Reduced ability to function in daily life

Test and Diagnosis 1. Lab tests Blood pressure Cholesterol Blood sugar 2. Neurological exam: Reflexes Muscle tone and strength, and how strength on one side of body compares with the other side Ability to get up from a chair and walk across the room Sense of touch and sight Coordination Balance 3. Brain imaging Images of the brain can pinpoint visible abnormalities caused by strokes, blood vessel diseases, tumors or trauma that may cause changes in thinking and reasoning. A brain-imaging study can help diagnose the cause of symptoms and rule out other causes.

Computerized tomography (CT). A CT scan can provide information about your brain's structure; tell whether any regions show shrinkage; and detect evidence of strokes, mini strokes (transient ischemic attacks, blood vessel changes or tumors. Magnetic resonance imaging (MRI). An MRI uses radio waves and a strong magnetic field to produce detailed images of your brain. MRIs can provide even more detail than CTs about strokes, mini strokes and blood vessel abnormalities. Carotid ultrasound.This procedure uses high-frequency sound waves to determine whether the carotid arteries which run up through either side of the neck to supply blood to brain show signs of narrowing as a result of plaque deposits or structural problems. This test may include a Doppler ultrasound, which shows the movement of blood through thearteries in addition to structural features. Neuropsychological tests This type of exam assesses the ability to:
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Speak, write and understand language Work with numbers Learn and remember information Develop a plan of attack and solve a problem Respond effectively to hypothetical situations

Neuropsychological tests sometimes show characteristic results for people with different types of dementia. People with vascular dementia may have an exceptionally hard time analyzing a problem and developing an effective solution. They may be less likely to have trouble learning new information and remembering than are people with Alzheimer's unless their blood vessel problems affect specific brain regions important for memory. However, there's often a lot of overlap in exam results for people with vascular dementia and people who have Alzheimer's disease Treatments and drugs Alzheimer's medications

Cholinesterase inhibitors including donepezil (Aricept), galantamine (Razadyne) and rivastigmine (Exelon) work by boosting levels of a brain cell chemical messenger involved in memory and judgment. Side effects can include nausea, vomiting, muscle cramps and diarrhea. Memantine (Namenda) regulates another brain cell chemical messenger important for information processing, storage and retrieval. Side effects can include headache, constipation, confusion and dizziness.

Nursing Care 1. Monitor the effectiveness and potential side effects of medications given to improve cognitive function or delay cognitive decline. 2. Provide appropriate cognitive-enhancement techniques and social engagement. 3. Ensure adequate rest, sleep, fluid, nutrition, elimination, pain control, and comfort measures. 4. Avoid the use of physical and pharmacologic restraints. 5. Maximize functional capacity: Maintain mobility and encourage independence as long as possible, provide graded assistance as needed with ADLs and IADLs, provide scheduled toileting and prompted voiding to reduce urinary incontinence, encourage an exercise routine that expends energy and promotes fatigue at bedtime, establish bedtime routine and rituals. 6. Address behavioral issues: Identify environmental triggers, medical conditions, caregiverpatient conflict that may be causing the behavior, define the target symptom (i.e., agitation, aggression, wandering) and pharmacological (psychotropics) and nonpharmacological (manage affect, limit stimuli, respect space, distract, redirect) approaches, provide reassurance; refer to appropriate mental-health care professionals as indicated. 7. Ensure a therapeutic and safe environment: Provide an environment that is modestly stimulating, avoiding overstimulation that can cause agitation and increase confusion, and understimulation that can cause sensory deprivation and withdrawal. Utilize patient identifiers (name tags), medic alert systems and bracelets, locks, wander guard; eliminate any environmental hazards and modify the environment to enhance safety; provide environmental cues or sensory aides that facilitate cognition; maintain consistency in caregivers and approaches.

8. Provide appropriate end-of-life care in terminal phase: Provide comfort measures including adequate pain management; weigh the benefits/risks of the use of aggressive treatment (tube feeding, antibiotic therapy). 9. Provide caregiver education and support: Respect family systems/dynamics and avoid making judgments, encourage open dialogue, emphasize the patients residual strengths, provide access to experienced professionals, teach caregivers the skills of caregiving. 10. Integrate community resources into the plan of care to meet the needs for patient and caregiver information; identify and facilitate both formal (i.e., Alzheimers Association, Respite Care, Specialized Long Term Care) and informal (i.e., churches, neighbors, extended family/friends) support systems.