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vascular dementia and Alzheimer Disease challenges and grey zone of uncertainty Kamal KALLAB history • Thomas WILLIS, 1684 – “A palsy, often succeeds stupidity or becoming foolishness” • Otto BINSWANGER, 1894 – Arteriosclerotic insanity in opposition to syphilitic dementia paralytica • Vladimir HATCHINSKI, 1974, – coined “Multi infarct dementia” epidemiology • Cerebro-vascular diseases: – First cause of handicap – Third cause of death – May lead to cognitive impairment, and sometimes to dementia • VaD: Second most common form of dementia after Alzheimer’s disease. – Why do some patients with stroke have cognitive impairment ? • Men more than women • Start at a younger age than Alzheimer • Increase with age Relation vacular lesions and dementia CvD postmortem Clinical dementia Adjusted OR Lacunes 1 to 2 93% 20.7 More than one large infarct 75% 6.7 No infarct - 57% Pathology • Parenchymal lesion: – Ischemic • • • • • Large Multi-infarct of large arteries territory Unique strategic lesion Lacunar hypoperfusion Binsawnger and other white matter subcortical diffuse lesions – hemorragic MID • Most common form • Damage caused to the cortex of the brain • Association of cortical signs – – – – Mortor Sensory Language Memory (other than verbal) nor always impaired – Symptoms may include severe depression, mood swings and epilepsy Strategic location of stroke • ( THALAMUS, PCA INARCTION INVOLVING TEMPORAL LOBE, ANTERIOR LIMB OF INTERNAL CAPSULE, wernicke area, ETC.) Small vessel diseases, lacunar • Frontal lobe deficits – Executive dysfunction – Inattention • Depressive mood changes • Changes in gait: Small steps gait • slowness • Pseudobulbar syndrom • Frontal signs • Urinary urgencies • Memory not always impaired Diffuse white matter disease • Damage to tiny blood vessels of the white matter, deep within the brain. • Silent • Then slowly progressive!!! • Slowness, lethargy, difficulty walking, emotional ups and downs, lack of bladder control. Clinical pictures (common) • • • • • Risk factors TIAs Temporal relation with vascular events Stepwise Primary zones: motor, somesthesic, sensory are usually involved • Memory not always impaired Progression of Vascular Dementia Onset gradual or dramatic Stabilise TIA/Stroke Stabilise TIA/Stroke Typically Vascular Dementia progresses gradually in a stepwise fashion in which a person’s abilities deteriorate after a stroke, then stabilise until the next stroke. Training to care for people with dementia • Primary prevention: – Treatment of HTN, DM, hypercholestrolemia, avoid smoking • Secondary prevention: – More aggressive control of HTN, DM and hypercholestrolemia – Anti-platelet agents like Aspirin and Plavix – Warfarin in patients with Atrial fibrillation – Possible surgery in patients with documented carotid artery stenosis Treatment of dementia • WHEN IN DOUBT, GET RID OF MEDICATIONS! • Classical treatement for Alzheimer disease may be effective (is it because of mixed forms) VaD v/s Alzheimer • Degenerative diseases and cerebro-vascular diseases are both frequent • They are both associated with age and increase in incidence and prevalence with age • On autopsy series, there is a frequent association of degenerative pattern and vascular ischemia AD Va D OTHER CELLULAR AND TISSUE DEMENTIAS VaD v/s Alzheimer • VaD diagnostic criteria are nor accurate • No definite marker – MMS, Hutchinski and DSM-IV – Imaging – biology • VaD can be progressive • Alzheimer can present with acute episodes • Selective studies showed some benefit of Alzheimer medications in VaD • Epidemiological studies found an independent correlation between Alzheimer and HT (wich is a risk factor for VaD) (Kuopio et Göteborg) but also for A Fib, Hypercholesterolemia, diabetes? • Genetic link: ApoE4 et renine angiotensine both play a role in AD and Cerebrovascular disease Comprehensive view BRAIN CAPITAL • Reasons of growth: – Initial genetics – Training and memory – Extra Intellectual effort • Reasons for loss – Progressive neurons loss – Rapid loss (Alzh) – Acute diseases: • • • • Infectious Vascular TBI Toxic (alcohol) Bank Account • Reasons of growth: – Initial capital – interest – Investment • Reasons for loss – Usual inflation rate – Unusual inflation rate – Accidents: • • • • financial crisis, bad management, bankruptcy Risky behavior • Alzheimer disease tend to be more severe in case of other previous or concomitant brain destruction • Impact of any acute lesion on the brain is beyond expected if there is an Alzheimer disease Fight for brain – Cardiology, oncology, surgery and infectious diseases control add years to life – Protecting the brain will Add life to years – unique battle against all brain diseases • Curable: metabolic, some brain tumors, subdural hematoma, hydrocephalus,.. • Preventable – Highly preventable: infectious, metabolic, toxic and traffic and professional trauma – Reasonably preventable: vascular – Poorly preventable: degenerative • Treatable, with variable results Let us add life to years