Vascular Dementia or Dementia with Cerebro-Vascular Disease : - PowerPoint PPT Presentation

Vascular Dementia or Dementia with Cerebro-Vascular Disease : Changes in Concepts Jean- -Marc Marc Orgogozo Orgogozo, MD , MD Jean Professor Professor Department of Clinical Neurosciences Department of Clinical Neurosciences INSERM U- -897 897 INSERM U University of Bordeaux - - France France University of Bordeaux EMEA, London, 11 Feb Feb. 2007 . 2007 EMEA, London, 11

Current concepts on on dementia dementia Current concepts Excessive emphasis on on memory disturbances memory disturbances : : Excessive emphasis - Based Based on on the cortico the cortico- -hippocampic type hippocampic type (AD) (AD) - - Not Not applicable applicable to to the sub the sub- -cortical cortical and and fronto fronto- -temporal temporal - types, , more frequents more frequents in in VaD VaD types The DSM DSM- -IV IV definition is loose definition is loose : : The - 1) 1) memory loss memory loss + 2) + 2) cognitive impairment cognitive impairment x and y x and y (+ z…) (+ z…) - = dementia dementia if if (and (and only if only if) ) there is there is 3) a 3) a functional loss functional loss = - Executive dysfunction Executive dysfunction is often is often prominent in prominent in VaD VaD : : - alternative to memory loss memory loss as as first criterion first criterion? ? It drives the It drives the alternative to early functional loss… … early functional loss WHO ICD- -10 : 10 : Dementia is not only Dementia is not only a a dysmnesia dysmnesia WHO ICD

Definition of VaD VaD Definition of VaD is an etiological category of dementia in ICD-10 - Includes dementia resulting from cerebral ischemia Includes dementia resulting from cerebral ischemia - or hemorrhage (post- -stroke dementia) stroke dementia) or hemorrhage (post - Much rarer : dementia from global Much rarer : dementia from global hypoperfusion hypoperfusion - (post- -CABG or post CABG or post- -CHF) CHF) (post - BUT: the definition of BUT: the definition of dementia dementia needs to be clarified: needs to be clarified: - phenocopy of AD or broader definition? of AD or broader definition? phenocopy

Diagnosis of VaD: NINDS-AIREN criteria Dementia + Cerebrovascular disease • Impaired memory (?) • History of CVD (3-month) • ≥ 2 other cognitive domains •Neurological examination impaired • Neuroimaging Probable/Possible diagnosis • Temporal relationship between CVD and dementia • Abrupt onset/stepwise progression • Absence of disorders that could account for deficits (eg, AD) Diagnosis of VaD VaD Diagnosis of Román GC et al. Neurology. 1993;43:250-60

Alternative Definitions Alternative Definitions Vascular cognitive disorder (VCD): a diagnostic category that includes any degree of cognitive impairment resulting from cerebrovascular disease [CVD]. Includes : Vascular cognitive impairment (VCI): isolated cognitive dysfunction, not qualifying as dementia, and ): cognitive impairment causing cognitive impairment causing Vascular Dementia (VaD VaD): Vascular Dementia ( dementia, both resulting from ischemic or hemorrhagic dementia, both resulting from ischemic or hemorrhagic CVD (post- -stroke dementia); or from stroke dementia); or from hypoperfusion hypoperfusion CVD (post (hypotension, post coronary artery bypass graft [CABG] or (hypotension, post coronary artery bypass graft [CABG] or post congestive heart failure [CHF]) post congestive heart failure [CHF]) • Roman et al, J • Roman et al, J Neurol Neurol Sci Sci, 2004 , 2004

Executive Control Functions Executive Control Functions “Command and control” of complex goal- directed action Examples include initiation, sequencing and monitoring of complex behavior Executive dysfunction is expressed as disorganized thought, behavior, or emotions ECF was added to the DSM-IV definition of dementia in 1994 DSM- -IV: Diagnostic and Statistical Manual of Mental Disorders, 4th e IV: Diagnostic and Statistical Manual of Mental Disorders, 4th edition (1994). dition (1994). DSM

Executive dysfunction in vascular Executive dysfunction in vascular dementia dementia 1 although not mandatory Is a characteristic feature of VaD 1 although not mandatory Is a characteristic feature of VaD in current criteria in current criteria Includes difficulties in planning, organization, Includes difficulties in planning, organization, problem- -solving, conceptualization, mental flexibility solving, conceptualization, mental flexibility problem Leads to difficulties in performing instrumental activities of Leads to difficulties in performing instrumental activities of 2 Such as managing finances, phoning, daily living (IADL) 2 daily living (IADL) Such as managing finances, phoning, transportation, medication, engaging in hobbies 3 3 transportation, medication, engaging in hobbies 1 Rom 1 Romá án GC, Royall DR. Alzheimer n GC, Royall DR. Alzheimer Dis Dis Assoc Assoc Disord Disord. 1999;13:S69 . 1999;13:S69- -80 80 2 Pohjasvaara 2 Pohjasvaara T, et al. T, et al. Eur Eur J J Neurol Neurol. 2002;9:269 . 2002;9:269- -75 75 3 3 Dartigues et al, PAQUID Study, 1994 Dartigues et al, PAQUID Study, 1994

Key differentiating factors Key differentiating factors Alzheimer’s disease Vascular dementia Insidious onset Sudden onset Progressively Fluctuating, stepwise deteriorating course course with plateaus No early focal Early focal neurological neurological signs symptoms & signs No vascular damage on brain Evidence of relevant vascular imaging brain damage Moroney et al et al. . Neurology 1997; 49: 1096 Neurology 1997; 49: 1096– –105 105 Moroney

Epidemiology: Prevalence of AD + CVD in the elderly Year Population (%) Rochester 1 1987 9 Appiganano 2 1990 13 Gothenburg 3 1993 8.2 Canadian IVIC 4 2000 7.5 Canadian SHA1 (VCI/AD) 5 2000 8 Campo Grande 6 2002 37 Cardiovascular Health Study 7 2003 16 Overall: 10–20% 1. Schoenberg Schoenberg et al et al. Ann . Ann Neurol Neurol 1987; 1987; 2. 2. Rocca Rocca et al et al. . Neurology Neurology 1990; 1990; 3. 3. Skoog Skoog et al et al. N . N Engl Engl J J 1. Med Med 1993; 1993; 4. 4. Rockwood Rockwood et al et al. . Ann N Y Ann N Y Acad Acad Sci Sci 2000; 2000; 5. 5. Rockwood Rockwood et al et al. . Neurology Neurology 2000; 2000; 6. 6 . Yamada Yamada et al et al. . Psychiatry Psychiatry C Cli lin n Neurosci Neurosci 2002; 2002; 7. 7. Lopez Lopez et al et al. . Neuroepidemiology Neuroepidemiology 2003; 2003;

Stroke and VaD Worldwide, stroke has affected Worldwide, stroke has affected ≈ 31 million people 1 ≈ 31 million people 1 25% to 41% may develop VaD 2 25% to 41% may develop VaD 2 ≈ 8 to 13 million people with VaD VaD ≈ 8 to 13 million people with caused by stroke caused by stroke 1 1 Murray & Lopez. WHO global health statistics. 1996; Murray & Lopez. WHO global health statistics. 1996; 2 2 Román. J Román. J Neurol Neurol Sci Sci. 2002 . 2002

Poststroke Dementia Prevalence Helsinki: 6% to 25.5% New York City: 27% to 41% USA: 1 million cases Europe: 800,000 VaD cases Global prevalence of VaD in Europe: 16/1000 after age 65 52/1000 after age 90 EURODEM. Neurology. 2000; 54 (suppl suppl 5). 5). EURODEM. Neurology. 2000; 54 (

Poststroke Dementia Incidence United States: 150,000 new cases/y 1/3 of the 360,000 incident cases of AD Europe: 134,000 new cases/y Incident stroke cases: → 536,000/y EURODEM. Neurology. 2000; 54 (suppl suppl 5). 5). EURODEM. Neurology. 2000; 54 (

VaD Is More Than MID… Is More Than MID… VaD Strategic single strokes: thalamic dementia, inferior genu lacune, caudate stroke White matter incomplete ischemia: Binswanger’s disease, CADASIL* Subcortical Ischemic Vascular Dementia: small- vessel disease with multiple lacunar strokes CADASIL= cerebral autosomal CADASIL= cerebral autosomal dominant dominant arteriopathy arteriopathy + + subcortical subcortical infarcts & infarcts & leukoencephalopathy leukoencephalopathy . .

1) Large-Vessel Disease => Large ischaemic areas ischaemic areas => Large => Large ischaemic areas Discrete infarcts in Discrete infarcts in strategic locations strategic locations Discrete infarcts in strategic locations Frontal Frontal Hippocampus Hippocampus, , Gyrus Gyrus Parietal- - Frontal Hippocampus, Gyrus Parietal Parietal- lobe basal forebrain angularis occipital lobes lobe lobe basal forebrain basal forebrain angularis angularis occipital lobes occipital lobes Aphasia, , apraxia apraxia, , Amnesia Constructional Alexia, Aphasia Aphasia, apraxia, Amnesia Amnesia Constructional Constructional Alexia, Alexia, disinhibition disinhibition, , apathy apathy problems problems agraphia, ,apraxia apraxia disinhibition, apathy problems agraphia agraphia,apraxia Cortical type of dementia - MID Cortical type of dementia - MID

Large vessel infarctions Large vessel infarctions Cortical VaD Cortical VaD Soubcortical VaD VaD Soubcortical Left cortico cortico- -subcortical subcortical Left Left thalamic infarct Left thalamic infarct occipito- -temporal infarct temporal infarct occipito