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Dementia is a syndrome that incorporates a wide range of different brain problems. Although most professional definitions of dementia are based on memory dysfunction, but cognitive impairment can be damaging when memory is reasonably intact and functions like voice and decision-making are impaired. Cognitive impairment can result from damage to the central nervous system(Korczyn, Vakhapova and Grinberg, 2012).
- The clinical phenotype caused by brain injuries is determined by a number of parameters, including the location and size of the lesions, the amount and site of neuronal loss, and the regions of the brain in which the lesion occurred. It occurs when brain tissue is damaged due to a reduction in blood supply.
- A partial blockage or a blood clot can limit or totally stop blood flow to brain tissue. Vascular dementia symptoms may appear gradually after a stroke or significant surgery, such as heart bypass surgery or abdominal surgery. Vascular changes are most common among the elderly, whose brains are likely to be damaged by age-related degenerative changes and other disorders(Langa, Foster and Larson, 2004). The most prevalent form of vascular brain disease is associated with a stroke.
- Multiple vascular disorders, such as haemorrhage, infarction, hippocampal sclerosis, and white matter lesions, can arise in the ageing human brain, resulting in a variety of cerebral tissue abnormalities(Grinberg and Thal, 2010).
Stages in vascular dementia
- Decision-making and thinking are frequently affected first by vascular dementia, followed by memory problems. In the early stages, symptoms may include difficulty thinking or confusion, difficulty making decisions, and difficulty following a series of steps (for example making a cup of tea or cooking a meal).
- As the condition worsens, it damages all brain functions, and the symptoms can resemble those of Alzheimer's disease in its later stages.
- Later stages include increased confusion, mood swings, and memory problems. In the later stages, people may experience hallucinations.
- Although there is no cure for vascular dementia, considering adjustments to your risk factors, such as exercising, eating a healthy diet, and taking blood pressure and cholesterol medication, can help to delay the progression.
Anatomy of Vascular Dementia
- MRI scans virtually consistently reveal abnormalities in the brain of people with vascular dementia. Diseased small blood vessels and alterations in "white matter" are also common in the brains of persons with vascular dementia. Ionic pumps which maintain and restore the ionic gradients lost by synaptic activity, consume the majority of energy in neurons(Harris, Jolivet and Attwell, 2012). Because there are fewer synapses, white matter energy usage, and thus blood flow, is one-third that of grey matter. Certainly, white matter lesions have a wide range of effects on brain structure and function, including decreased frontal lobe glucose utilisation(Haight et al., 2013), a global decrease in cortical blood flow(Chen, Rosas and Salat, 2013)(Ten Dam et al., 2007), brain connectivity disruption(Lawrence et al., 2013), and cerebral atrophy(Appelman et al., 2009).
- There is a strong correlation between cardiovascular illness, which affects the heart and blood vessels, and cerebrovascular disease, which affects the brain, along with cognitive impairment and dementia, as per research. The critical role of cerebral blood arteries in brain health is central to the disease mechanism, not only for the transport of oxygen and nutrients, but also for the trophic signals that connects the well-being of neurons and glia to that of cerebrovascular cells(Iadecola, 2013).
Physiology of Vascular Dementia
- Behavioral and psychological symptoms of dementia (BPSD), also known as neuropsychiatric symptoms, are a diverse group of non-cognitive symptoms and behaviours that occur in dementia patients. They are clinically relevant in the same way that cognitive symptoms are, because they strongly correlate with the degree of functional and cognitive impairment. Agitation, abnormal motor behaviour, anxiety, elation, irritability, depression, passivity, impulsive behaviour, delusional thoughts, hallucinations, and changes in sleep or appetite are all symptoms of BSPD(Cerejeira, Lagarto and Mukaetova-Ladinska, 2012).
- The most consistent finding from studies comparing vascular dementia (VaD) to Alzheimer's disease (AD) is that subjects with VaD have a relatively high prevalence and severity of depression and anxiety, comparable levels of psychotic symptoms, and less severe abnormal motor behaviour, despite the fact that there can be significant overlap between the two dementia syndromes(Fernandez-Martinez et al., 2008).
- Accordingly, the type of innate vascular disease appears to influence the clinical profile of vascular dementia (VaD), with apathy, abnormal motor behaviour, and hallucinations associated with small-vessel vascular dementia ( VaD), whereas euphoria and agitation/aggression were more severe in patients with large-vessel vascular dementia (VaD)(Staekenborg et al., 2010).
Signs and Symptoms of Vascular Dementia
The symptoms of vascular dementia vary according to which part of the brain is affected. The severity of the symptoms is based on the length of period the brain was without oxygen and blood(Lee, 2011). Most symptoms overlap with those of other types of dementia, and not all of them are obvious(Mijajlovi? et al., 2017)
The following are the most prevalent signs and symptoms of vascular dementia:
- Confusion and memory issues
- Having trouble paying attention and focusing
- Having difficulty completing tasks that were once simple(such as bill payment)
- Hands, feet, arms, and legs are all prone to weakness.
- a tendency to become angry or upset easily
- Visible personality or behavioural changes
- Depression and stress
- frequently feeling lost or left out
- difficulty regulating urination or regularly wanting to urinate
- difficulty finding or using the appropriate term( at times language problems)
- hallucinations and delusions
- Having difficulty making decisions
- Loss of ability to perceive danger
- Difficulty in reading and writing
Impact of Vascular Dementia on body
- Insufficient blood flow can harm and eventually kill cells throughout the body, but the brain is particularly vulnerable. This can occur as a result of narrowing and blockage of the brain's tiny blood vessels. A single stroke occurs when the blood flow to a portion of the brain is abruptly cut off. After a stroke that clogs major blood arteries in the brain, vascular dementia causes rapid alterations in thinking skills.
- Heart attack and stroke-The left ventricle thickens to the point where it can no longer effectively pump blood throughout the body. The plaque protein accumulation was responsible for the thickness (same as in patient’s brain, seen in Alzheimer’s).
- Blood vessels in the brain are damaged by high blood pressure, diabetes, and atherosclerosis. Due to blood clots in the heart, atrial fibrillation raises the risk of stroke. Stroke risk is also increased by disorders that induce excessive clotting.
Impact on daily life
Quality of life (QOL) in Vascular Dementia (VaD) is based on Lawton’s work, assessment based on subjective and objective factors(Ready and Ott, 2005). There were four dimensions that contributed to QOL in dementia:
- Psychological well being ( both positive and negative)
- Behavioural competence ( cognitive and functional abilities)
- Objective environment ( for example- caretakers and living situation)
- Perceived QOL
- Vascular Dementia is a disease that worsens over time. Although each person's experience with dementia is unique, as are their needs for care and support, people with dementia have common daily issues such as washing, dressing, eating, and bathing. Basics ADLs (activities of daily life), such as eating, bathing, dressing, and toileting, are referred to as ADLs. The skills required for functioning in society and the community are known as instrumental ADLs. As dementia develops, the skills required for ADLs decline.
- When a person can no longer perform simple math calculations, their finances must be managed by a caretaker or financial counsellor. Medical decision-making and medication management will also fall into the hands of a caregiver when insight is limited and memory is severely impaired. Guardianship and capacity evaluations are common, particularly when estate and legal concerns need to be resolved(Defina et al., 2013)
Care and monitoring
Caregivers' obligations rise as independence declines, despite the fact that there is often no apparent distinction between mild, moderate, and severe dementia. Nursing plans can also be referred to in order to gain information and confidence on how to look after patients suffering from vascular dementia(D’Onofrio et al., 2015).
For caregivers, these are the tips to keep in mind:
- Determine the cause of the change in behaviour: Examine the scenario to see if the shift was caused by a behavioural trigger or antecedent. Keep in mind that if the individual is in pain or discomfort, they may not be able to appropriately convey their distress. Caregivers can often detect signs of distress in a person's conduct.
- Practice patience, acceptance, and flexibility: When the behaviour problems become overwhelming, it is critical to seek help. Caregiver support groups are beneficial because they provide a safe place to vent, feel sorrow, and gain practical advice from others who are facing similar challenges(D’Onofrio et al., 2015).
Advised plan with justifications.
Check the patients level of confusion
To supervise the efficiency of treatment and therapy.
Switching to one-to-one nursing
Makes the patient comfortable, better relationship, maintaining dignity , while safely performing all the ADLs
Simplify the task, keep the language and medium of communication easy.
Patients have difficulty responding to complex tasks.
Provide opportunities but be flexible in your approach
Prevents feeling isolated but could also agitate the patient
Monitoring vascular dementia
Doctors have devised a number of methods for detecting and monitoring dementia once it has been identified. Therefore, follow these steps-
- Regular follow-up appointments: if the patient has been prescribed with some drug treatments for vascular dementia, it is mandatory to receive the initial follow-up appointments to ensure the drug tolerance by the body and monitor any potential side effects.
- Memory Tests: Memory tests can help determine whether the vascular dementia symptoms have progressed or remained the same. For example, if the patient’s memory is deteriorating, it should be apparent in the test and may indicate that more assistance and support is needed to continue living well. Further follow-up appointments are typically held every six to twelve months and may include a memory test, but only if the person is comfortable and does not feel distressed or agitated.
- CT scans: If the person has been referred to a hospital for a CT scan during their dementia diagnosis, they should be offered follow-up scans every two or three years to detect any further physical changes inside the brain. For example-If diagnosed with Alzheimer's disease, the CT scan may reveal further loss of brain cells in the temporal lobe. In the case of lewy body dementia or vascular dementia, any further brain cell loss will become more general and widely spread.
The most recent CT scan would show the progression of vascular dementia in a person and thereby help in better management and more effective treatment.
- MRI scans: These provide a clearer, more detailed picture of the brain than a CT scan and are impactful enough to unveil even the smallest changes to 'grey matter’ and 'white matter'. For example, in the case of vascular dementia, the doctor will be looking for any further changes in the white matter of the brain, as this is where the disease's most visible symptoms occur.
- The Brief Cognitive Rating Scale (BCRS) and the Global Deterioration Scale (GDS) are two very detailed tests conducted by doctors that can reveal which stage of the vascular dementia journey someone is in(Sheehan, 2012).
Treatment of vascular dementia
Clinical trials of drugs and therapies
- Memantine- Memantine is an antiparkinson and antiviral medication that belongs to the aminoadamantane chemical class. It is structurally similar to amantadine.
- Galantamine- Galantamine is a cholinesterase inhibitor and n-cholino receptor modulator that has been shown to help with the symptoms of vascular dementia.
- When donepezil was compared to a placebo, it was discovered that donepezil had a positive impact on cognitive performance, overall assessment, and everyday activities.
- Rivastigmine Rivastigmine inhibits acetylcholinesterase (AChE) and butyrylcholinesterase (BChE) without being specific (BuChE). Rivastigmine's efficacy in vascular dementia hasn't been well examined enough to draw any conclusions.
- Hydergine Hydergine, also known as ergoloid mesylates, is a combination of four dihydro-derivatives of ergotoxine that has been used in clinical medicine since 1949 to treat a number of illnesses. It is currently licenced by the US Food and Drug Administration (FDA) for the treatment of people with dementia or "age-related" cognitive impairments.
- Blood Pressure- lowering therapies- It's a fascinating topic, both scientifically and therapeutically, if removing one of the known risk factors for vascular dementia, high blood pressure, will lessen the prevalence of the disease.
- Validation therapy is a set of nonpharmacologic procedures for treating demented people's disorientation and confusion. In dealing with these patients, empathy and consideration of emotional states are emphasised(Baskys and Hou, 2007).