Vascular dementia: Changing the paradigm

Purpose of the review: Recent progress in the field of vascular dementia is summarized, including a conceptual redefinition, and advances in the understanding of its pathogenesis, diagnosis, treatment and prevention. Recent findings: Vascular dementia is second only to Alzheimer's disease in frequency, according to population-based epidemiological studies, including neuropathological data. Projections based on growth of the elderly population and a rising incidence of ischemic heart disease and stroke suggest that vascular dementia may become the commonest form of dementia. Vascular factors in Alzheimer's disease continue to be an area of major research effort. Lacunes carry a poor long-term prognosis; silent lesions found on magnetic resonance imaging more than double the risk of dementia. Common manifestations of vascular dementia include executive dysfunction, abnormal gait, apathy and depression ('vascular depression'). A new therapeutic indication of cholinesterase inhibitors may result from positive results of phase III trials in vascular dementia. Diagnosis of vascular cognitive impairment should lead to prevention of dementia by appropriate control of risk factors and vascular brain burden. Summary: Vascular dementia is an important and often overlooked form of dementia in the elderly. Cholinergic treatment may improve prognosis. Primary prevention of vascular dementia and Alzheimer's disease appears to depend on early identification and appropriate control of vascular risk factors. Secondary prevention, after clinical stroke or silent lacunes, must include energetic therapy to prevent stroke recurrence.