Vascular dementia | Causes, symptoms, stages & diagnosis

Subcortical vascular dementia is caused by diseases of the very small blood vessels that lie deep in the brain, known as small vessel disease. Over time, these blood vessels can develop thick walls and become stiff and twisted, so blood cannot travel through them easily. The parts of the brain supplied by these blood vessels become starved of oxygen and nutrients. Eventually they stop working altogether and the affected brain cells are lost.

Vascular dementia can also be caused by a stroke; this form of dementia is known as stroke-related dementia or post-stroke dementia. This occurs when the blood supply to a part of the brain is suddenly cut off. With most strokes, a blood vessel in the brain becomes narrowed and is blocked by a clot.

The clot may have formed in the brain or, if someone has heart disease, it may have formed in the heart and been carried to the brain. Sometimes, it is because the vessel bursts and bleeds into the brain, but this is much less common.

Multi-infarct dementia is caused by a series of smaller strokes. This may also include transient ischaemic attacks (TIA). A TIA is similar to a stroke but the symptoms last only a short time and tend to get better by themselves. Some people may not realise that they have had smaller strokes or a TIA. If the blood supply is interrupted for more than a few minutes or hours, the stroke may lead to permanent brain damage.

The areas of the brain affected by these strokes are known as infarcts. If a person has several smaller strokes over time, multiple infarcts will build up in their brain. They may eventually develop dementia if the combined damage of all these infarcts is enough to cause problems with memory, thinking or reasoning.

Mixed dementia is when a person’s dementia is caused by more than one condition. Most often it is a combination of Alzheimer’s disease and vascular dementia. At least one in every ten people with dementia is diagnosed with mixed dementia. In the most common form of mixed dementia, the abnormal protein deposits associated with Alzheimer’s disease coexist with blood vessel problems linked to vascular dementia.

Vascular dementia is most common in people aged over 65, and the risk increases as people grow older. However, it can also occur in younger people, and is the second most common form of young-onset dementia, which is where symptoms develop before the age of 65.

As vascular dementia often develops after a stroke, people with atrial fibrillation (AF) are at higher risk. AF is an irregular heart rhythm which increases the risk of stroke. Vascular dementia is slightly more common in men, and people from South Asian and African-Caribbean backgrounds are at increased risk. People with a family history of vascular dementia may also be at slightly greater risk.

Symptoms of vascular dementia

The impact of vascular conditions on thinking skills varies widely, depending on the severity of the blood vessel damage and the part of the brain it affects.

Generally, early signs include:

Concentration problems.
Poor short-term memory.
Difficulty with everyday skills.
Slowed thought processes.

There may also be changes in:

Behaviour.
Personality.
Ability to solve problems.
Ability to make decisions and plans.
Organisational skills.
Mood, particularly rapidly changing mood.

If someone develops symptoms of dementia after a stroke, they may also have speech or vision problems.

In subcortical vascular dementia the symptoms include:

Early loss of bladder control.
Speech problems.
Movement changes.
Personality and mood changes.
Increased risk of falls.
Reduced facial expressions.

Multiple small strokes or other conditions that affect blood vessels and nerve fibres deep inside the brain may cause more gradual thinking changes as damage accumulates. A person with subcortical vascular dementia will often have slowed thinking and problems with executive function. People with vascular dementia may have periods where their symptoms seem stable, but they will always worsen over time.

What part of the brain is affected by vascular dementia?

The brain comprises the cerebral cortex, which is a thin layer of cells covering the outside surface of the brain.

It is responsible for:

Memory.
Reasoning.
Decision-making.
Language.
Social skills.

It controls actions such as moving around or talking, as well as processing sight, hearing, taste, smell, touch and pain. The cerebral cortex can be divided into four ‘lobes’ (regions).

These are the:

Temporal lobes.
Frontal lobes.
Parietal lobes.
Occipital lobes.

Vascular dementia refers to changes to memory, thinking and behaviour resulting from conditions that affect the blood vessels in the brain. It often causes widespread damage to white matter beneath the cortex in the brain. The white matter connects the “wires” or nerve fibres of the brain that are critical for relaying messages between brain regions. These nerve fibres carry signals between different parts of the cortex, including the frontal lobes.

Our brains have about 90 billion nerve cells, sending messages to each other and allowing us to sense and respond to the world around us. Cells lose their ability to communicate with each other during dementia and they eventually die. This loss of nerve cells causes the symptoms of dementia.

Other abnormalities commonly found in the brains of people with vascular dementia are diseased small blood vessels.

What are the stages of vascular dementia?

The stages of vascular dementia are just a guide, as dementia doesn’t follow an exact or certain set of steps that happen in the same way for every person with dementia. It can be difficult to tell when a person’s dementia has progressed from one stage to another.

Some symptoms may appear in a different order for different individuals, the stages may overlap and the person may need help with some aspects of everyday life but manage other tasks and activities on their own. Some symptoms, particularly those linked to behaviours, may develop at one stage and then reduce or even disappear later on. Other symptoms, such as memory loss and problems with language and thinking, tend to stay and get worse with time.

Early vascular dementia can begin several years before any symptoms become apparent. In the early stage of all types of dementia only a small part of the brain is damaged. In this stage, a person has fewer symptoms as only the abilities that depend on the damaged part of the brain are affected.

The most common symptoms during the early stages of vascular dementia are:

Problems with planning or organising, making decisions or solving problems.
Difficulties following a series of steps such as cooking a meal.
Slower speed of thought.
Problems concentrating, including short periods of sudden confusion.

A person in the early stages of vascular dementia may also have difficulties with their memory; for example, they may have problems recalling names or recent events, although this may be mild. They may also have difficulties with their language, for example, their speech may become less fluent. Mild cognitive decline where forgetfulness becomes slightly increased can last for years.

A person may become depressed because they are worried about having dementia. Depression can also be caused by damage to parts of the brain that control emotions. Sometimes, a person with vascular dementia may experience stronger emotions than they did before. They may be prone to mood swings and being unusually tearful or happy.

As the symptoms become more prominent, many people get a diagnosis. At this stage, dementia patients may forget to pay their bills or have difficulties trying to work out money. They may also be unable to recall simple things, like what they ate for their last meal. This stage can last a couple of years.

As a person’s vascular dementia progresses, they may begin to behave in ways that seem out of character. For example, they may become more agitated or aggressive, or have sleep problems. They may also act in ways that others find embarrassing or difficult to understand. This may be because they are trying to communicate a need, for example, that they are hungry, confused, tired or in pain.

It could also be because the parts of their brain that tell them what is acceptable and control inhibitions no longer work properly, so the person doesn’t understand that what they are doing or saying is inappropriate.

When day-to-living starts to become difficult, they may struggle to remember things like their address, phone number, and how to dress appropriately, although may still be able to wash and feed themselves and use the toilet. Most people can recall family and friends, and they can typically recall childhood memories vividly.

In the latter stages, living independently isn’t usually possible. This is when symptoms such as incontinence can emerge, and difficulty swallowing can also occur at this stage. It is still possible for people to recognise loved ones, but they may be highly confused most of the time. More behavioural changes may also occur, with aggression and anger being somewhat common.

Most people with vascular dementia pass away before they experience very severe cognitive decline, usually from other health conditions, but in those who do reach this stage they require 24-hour care and supervision. Very severe decline means that in this final stage, people with vascular dementia will struggle to communicate or do almost anything independently.

How is vascular dementia diagnosed?

If you are worried about vascular dementia symptoms, talk to your doctor as soon as possible. Diagnosing vascular dementia as early as possible is important, as it means you can get the right treatments, support and help with the condition.

Your GP will:

Ask about your symptoms and how they are affecting you.
Ask a relative or close friend if they have noticed any changes.
Check your medical history.
Give you a physical check-up, checking your blood pressure and balance.
Run a blood test, to rule out some possible causes like vitamin deficiencies and thyroid disorders. They may also ask you for a urine sample.
Ask you to do some memory and thinking tests.

If your GP suspects dementia, you may be referred to a memory clinic or another specialist doctor, where you may have another physical check-up and complete some more memory and thinking tests. If possible, go to the assessment with a family member or friend so you can share experiences of the changes you have noticed. This person can also give support and listen to what is said at the appointment.

You may also be sent for other tests like a brain scan. Brain scans such as CT (computerised tomography) or MRI (magnetic resonance imaging) may be used to give a diagnosis of vascular dementia. The scans show the doctors changes in blood vessels or signs of a stroke/s.

Together the results of all of these tests will help the doctors to identify the likely cause of the symptoms. They may help to rule out a tumour or build-up of fluid inside the brain, which can have symptoms similar to those of vascular dementia. Some brain scans can also help tell the difference between vascular dementia and other types of dementia.

A person with dementia should receive a clear explanation of their diagnosis, if they want to know it. It should be explained in a way that they can understand. There should also be a discussion about the next steps and what support is available.

Can vascular dementia be treated?

There is no cure for vascular dementia, but there are treatment options available that can slow the progression of the condition and help with some of the symptoms. A doctor may prescribe or monitor medicines taken to treat the underlying conditions that can damage blood vessels and cause vascular dementia. These include medications for diabetes, stroke, high blood pressure, high cholesterol and heart problems.

If a person has stroke-related vascular dementia, it is important to reduce their risk of having another stroke as much as possible.

This means looking after their heart and blood circulation. For example, with support from doctors they can try to keep their blood pressure and blood sugar and cholesterol levels as normal as possible. They may also need to take drugs that thin their blood and prevent harmful clots. A person with vascular dementia should be supported to stop smoking.

Medications for Alzheimer’s disease are not effective for vascular dementia, unless the person has been diagnosed with mixed dementia. For people with both vascular dementia and Alzheimer’s (mixed dementia), there are some drugs that may help with the symptoms.

These include:

Cholinesterase inhibitors – These increase the amount of a chemical called acetylcholine that helps messages to travel around the brain. Cholinesterase inhibitors do not prevent the disease from getting worse but may help people to function better every day than they would do without the drug.
Memantine – This helps nerve cells in the brain communicate with each other. It does this by regulating a chemical called glutamate in the brain. Like cholinesterase inhibitors, memantine is not a cure or does not slow down the progression of the disease. However, it can help with some symptoms. Some people taking memantine may not notice any effect at all. Others may find that their condition stays the same when they would have expected it to decline.

Vascular dementia can sometimes cause a person to become agitated and distressed. These changes in behaviour may be because they are struggling to communicate a need or a feeling, or to understand what is going on around them. Positive interactions with other people, or activities matched to the person’s abilities and interests, can help.

Physical health problems such as pain, dehydration, infection or constipation can often cause a person with vascular dementia to become anxious, confused and disoriented. If these are serious, the person may develop delirium, which is an urgent medical problem that will require immediate treatment.

There are a variety of activities and therapies that can help a person with vascular dementia to maintain their abilities for as long as possible and to look after their physical and emotional well-being. Their availability will vary locally.

These include:

Cognitive stimulation therapy (CST) – This is a popular way to help keep someone’s mind active. It involves doing themed activity sessions over several weeks.
Cognitive rehabilitation – This is skills training that is tailored to a person’s needs and abilities. It can enable the person to keep their thinking skills, meet their goals and cope better with the symptoms of dementia.
Cognitive behavioural therapy (CBT) – This may be offered if the person develops depression or anxiety. It is most useful in the early stages of dementia.
Life story work – Many people with dementia enjoy this activity, where the person is encouraged to record their life experiences and memories. Knowing about a person’s life experiences may help others to provide person-centred care for them. Recording this information early on can also be helpful in the later stages of dementia, when a person may not be able to give this information.
Lifestyle changes – Research has shown that improving lifestyle can help slow down the progression of vascular dementia.

There are some small changes a person can make that might reduce the chance of more damage to the blood vessels in their brain:

Eat healthily.
Be physically active.
Keep to a healthy weight and lose weight if necessary.
Don’t smoke.
Cut down on alcohol.
Control high blood pressure.
Control cholesterol levels.
Control blood sugar levels (if they have diabetes).

Support available

Local authorities provide some practical support services and should arrange an assessment of care needs following a diagnosis. The type of services available may vary depending on where you live, but can include home, day and respite care. Access to specialist healthcare can be arranged through your doctor if needed.

If you are experiencing movement problems, for example after a stroke, you will often benefit from working with a physiotherapist or occupational therapist (or both). They can help you to move and stay independent, as well as advise on aids and adaptations in the home.

Support from a speech and language therapist (SLT) is often helpful if you develop problems with swallowing or speaking, which are particularly common after having a stroke. The GP or community nurse can make a referral to an SLT who can help you to keep eating well and communicate with others.

If you are supporting someone with vascular dementia you need to be aware that it is a progressive condition, so over time symptoms will get worse. This is generally over a period of several years. As vascular dementia progresses, a person is likely to become more confused or disoriented, and have more problems with memory, reasoning and communication.

In the later stages of the condition, they may become much less aware of what is happening around them. They may have difficulties walking or eating without help and may become increasingly frail. Eventually, someone with vascular dementia is likely to need a large amount of personal care.

This can put a strain on those caring for someone with vascular dementia, so you should consider respite care. This is any care arrangement designed to give rest or relief to unpaid carers.

Everyone needs a break from time to time. Carers are no different, and it is important that they are able to have a rest, whether it is a short break to run errands or meet friends, or longer time spent away.

Breaks are good for a carer’s physical and mental well-being and can enhance the relationship with the person they care for. The person with dementia may also benefit from the break. It could provide social interactions and opportunities to pursue hobbies and interests, remain involved and active, and form new relationships.

Final thoughts

There are a number of sources for information, advice and support for anyone concerned about their own vascular dementia health or for those supporting someone with vascular dementia, including:

Stroke Association 0300 3300 740.
Alzheimer’s Society 0333 150 3456.
Dementia UK 0800 888 6678.
British Heart Foundation 0300 330 3311.
Alzheimer’s Research UK 0300 111 5555.
NHS Respite Care.

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What is vascular dementia?