Vascular dementia

Description:

Dementia - the acquired mental disorder which is shown decrease in intelligence and breaking social adaptation of the patient (does it incapable of professional activity, the possibility of self-service is limited) and not followed by consciousness disturbance. Intellectual defect at dementia is characterized by complex disorder of several cognitive (cognitive) functions, such as memory, attention, the speech, гнозис, праксис, thinking, ability to plan, to make the decision, to control the actions. Unlike mental retardation at which frustration are noted since the birth dementia develops at the acquired organic lesions of a brain. Also do not refer the isolated disturbances of separate cognitive functions to dementia (aphasia, amnesia, agnosia, etc.) at which intelligence per se significantly does not suffer.

Vascular dementia makes 15-20% of all cases of dementia and the second for frequency is in countries of Western Europe and the USA. But in some countries of the world, such as Russia, Finland, China and Japan, vascular dementia takes the 1st place and meets more often than Alzheimer's disease. In 20% of cases of vascular dementia reminds Alzheimer's disease on a current, and in 10-20% of cases there is their combination. Modern basic researches demonstrate that vascular brain insufficiency is one of important factors of a pathogeny of Alzheimer's disease. The risk of developing of Alzheimer's disease and rate of progressing of the cognitive disturbances connected with this disease is higher in the presence of cardiovascular pathology, for example than atherosclerosis of cerebral arteries and an idiopathic hypertensia. On the other hand, the deposits of b of amyloid connected with Alzheimer's disease in a vascular wall can lead to development of an amyloid mikroangiopatiya which aggravates insufficiency of blood supply of a brain. Thus, the main forms of dementia (Alzheimer's disease and vascular dementia), on modern representations, are pathogenetic very closely connected among themselves.

The problem of vascular dementia is not only medical, but also social as this disease not only worsens quality of life of patients, but also leads to big economic losses owing to need of constant observation of patients with the expressed forms of vascular dementia. In Ukraine the main loading on a nosotrophy is born by his relatives. With aggravation of a condition of the patient load and of the trustee increases that leads to deterioration in the mental state which is looking after, and further to emergence or an aggravation of chronic somatopathies. In 1994 in work of R. Ernst and J. Hay it was shown that the persons which are carrying out patient care visited the general practitioner 46% more often and used medical supplies, than the people of the same age who are not looking after patients 71% more.

The importance of a problem of vascular dementia is defined also by the fact that life expectancy of patients is much less, than in the corresponding age population without dementia, and less, than at Alzheimer's disease. So, according to Skoog and coauthors, the lethality among patients with a vascular form of dementia in old age for 3 years made 66,7% whereas at Alzheimer's disease - 42,2%, and among not dementive probands - 23,1%. The highest risk of dementia is observed at patients with the had strokes (8,4% a year). Dementia develops at 26,3% in 2 months and at 31,8% of patients in 3 months after a stroke. And mortality of patients with postinsultny dementia in the next years after a stroke is 3 times higher, than at postinsultny patients without dementia.

Symptoms of Vascular dementia:

With the acute beginning emergence of cognitive disturbances for the first month (but no more than three months) after the first or repeated strokes is characteristic of dementia. Multiinfarctive vascular dementia is preferential cortical, it develops gradually (for 3-6 months) after a series of small ischemic episodes. At multiinfarctive dementia there is "accumulation" of heart attacks in a brain parenchyma. Existence of arterial hypertension and signs (clinical, tool) defeats of deep departments of white matter of cerebral hemispheres is characteristic of a subcortical form of vascular dementia. Subcortical dementia often reminds dementia at Alzheimer's disease. Differentiation of dementia in itself on cortical and subcortical is represented extremely conditional as pathological changes at dementia affect in a varying degree both subcrustal departments, and cortical structures.

Recently the attention is focused on the options of vascular dementia which are directly not connected with cerebral heart attacks. The concept of "not infarctive" vascular dementia has important clinical value as Alzheimer's disease is mistakenly diagnosed for the most part of these patients. Thus, these patients do not receive timely and adequate treatment, and vascular damage of a brain progresses. The basis for inclusion of patients in group of "not infarctive" vascular dementia is existence long (more than 5 years) the vascular anamnesis, lack of clinical and computer and tomographic signs of a cerebral heart attack.

One of forms of vascular dementia is Binswanger's disease (subcortical arteriosclerotic encephalopathy). For the first time described by Binswanger in 1894, it is characterized by the progressing dementia and episodes of acute development of focal symptomatology or the progressing neurologic frustration connected with defeat of white matter of cerebral hemispheres. Earlier this disease was carried to rare and diagnosed almost exclusively posthumously. But with implementation in clinical practice of methods of neurovisualization it turned out that Binswanger's encephalopathy meets quite often. It makes about a third of all cases of vascular dementia. Most of neurologists assume that this disease should be considered one of options of development of a hypertensive angioentsefalopatiya at which development of diffusion and melkoochagovy changes is observed, is preferential in white matter of hemispheres that is clinically shown by a syndrome of the progressing dementia.

On the basis of the round-the-clock monitoring of the ABP features of a course of arterial hypertension at such patients are revealed. It is established that at patients with vascular dementia of binsvangerovsky type higher rates of the average and maximum systolic ABP and the expressed its fluctuations for days are noted. Besides, such patients have no physiological decrease in the ABP at night and considerable raising of the ABP in morning is noted.

Feature of vascular dementia is the clinical variety of disturbances and a frequent combination of several neurologic and neuropsychological syndromes at the patient.

Delay, rigidity of all mental processes and their lability, narrowing of a focus of interest are characteristic of patients with vascular dementia. At patients are noted decrease in cognitive functions (memory, attention, thinking, orientation, etc.) and difficulties when performing functions in everyday life and life (service of, cooking, purchases, filling of financial documents, orientation in a new situation, etc.), loss of social skills, adequate assessment of the disease. Among cognitive disturbances first of all it should be noted a dysmnesia and attention which are noted already at a stage of initial vascular dementia and steadily progress. Decrease in memory on last and current events - the characteristic symptom of vascular dementia, however mnestichesky frustration are expressed more softly in comparison with dementia at OH. Disturbances of memory are shown mainly when training: are complicated storing of words, visual information, acquisition of new movement skills. Generally active reproduction of material while simpler recognition rather sokhranno suffers. At later stages disturbances of abstract thinking and judgments can develop. The expressed narrowing of volumes of any attention, considerable disturbances of its functions - concentration, distributions, switchings are defined. At vascular dementia syndromes of disturbance of attention have modal and nonspecific character and accrue in process of progressing of cerebrovascular insufficiency.

At patients with vascular dementia disorders of calculating functions take place, when progressing a disease the reaching acalculia degrees. Various speech disorders, disorders of reading and the letter come to light. Most often there are signs of semantic and anamnestic forms of aphasia. At a stage of initial dementia these signs are defined only when conducting special neuropsychological tests.

More than at a half of patients with vascular dementia the so-called emotional incontience (faintheartedness, violent crying), at a part of patients - a depression is observed. Development of affective frustration, psychotic symptomatology is possible. For vascular dementia the fluctuating type of a course of a disease is characteristic. Vascular dementia the long periods of stabilization and even the known involution of mnestiko-intellectual disturbances and therefore degree of its expressiveness fluctuates in this or that party that often correlates with a condition of a brain blood-groove are inherent.

In addition to cognitive disturbances patients with vascular dementia have also neurologic manifestations: pyramidal, subcrustal, pseudobulbar, cerebellar syndromes, paresis of muscles of extremities, are more often not rough, disturbance of gait as apraksiko-atactic or parkinsonichesky. Most of patients, especially old age, has disturbances of control of pelvic functions (most often an urine incontience).

Paroxysmal states - falling, epileptic attacks, syncopal states are quite often observed.

The combination of cognitive and neurologic disturbances distinguishes vascular dementia from Alzheimer's disease.

Reasons of Vascular dementia:

Understand decrease in cognitive functions as a result of ischemic or hemorrhagic damage of a brain owing to primary pathology of cerebral vessels or diseases of cardiovascular system as dementia of vascular genesis.

The most frequent etiological factors of vascular dementia are:
- ischemic strokes (aterotrombotichesky, embolic at defeat of big vessels, lacunary);
- intracerebral hemorrhages (at arterial hypertension, an amyloid angiopatiya);
- the subshell hemorrhages (subarachnoidal, subdural);
- repeated embolization owing to cardial pathology (an endocarditis, a myxoma of auricles, fibrillation of auricles and others);
- autoimmune vasculites (system lupus erythematosus, эритематоз, etc.);
- infectious vasculites (neurosyphilis, Lyme's disease, etc.);
- nonspecific vasculopathies.

Risk factors of vascular dementia
Treat risk factors of development of vascular dementia: the age is more senior than 60 years, arterial hypertension, arterial hypotension, a diabetes mellitus, a dislipidemiya, heart troubles (fibrillation of auricles, ischemic heart disease, heart diseases), diseases of peripheral vessels, smoking, a male, negroid and Asian races, heredity and other. It is interesting to emphasize that the low educational level and the worker's profession belong to estimated risk factors. Higher education level can reflect big abilities and reserves of a brain, removing, thus, in time the beginning of cognitive frustration.

Arterial hypertension is a major factor of risk of development and progressing of vascular dementia. It is connected as with high prevalence of AG among elderly people, and with the nature of specific defeat of vessels of a brain at arterial hypertension.

The conducted long-term epidemiological researches showed communication of arterial hypertension with cognitive disturbances, for example the research Honolulu-Asia Aging Study, as well as the fact that therapy on decrease in the ABP can reduce risk of dementia. These data were convincingly confirmed in the researches Systolic Hypertension in Europe trials, PROGRESS, LIFE, SCOPE, MOSES.

Treatment of Vascular dementia:

Knowledge of etiopatogenetichesky mechanisms of formation of vascular dementia, risk factors, data of evidential medicine allowed to formulate the basic principles of treatment and prevention of vascular dementia. The first stage is confirmation of the diagnosis of dementia. At the same time special value has identification of predementive states at which therapeutic opportunities are much wider.

Principles of treatment of vascular dementia:
1) etiopatogenetichesky;
2) drugs for improvement of cognitive functions;
3) symptomatic therapy;
4) preventive.

Treatment of vascular dementia has the differentiated character that is defined by heterogeneity of pathological process. Owing to a large number of etiopatogenetichesky mechanisms there is no uniform and standardized method of treatment of this category of patients. Treatment of vascular dementia has to include the actions directed to a basic disease against the background of which dementia, and on correction of the available risk factors develops. Considering that a major factor of risk is AG, the important role is given to its normalization as adequate anti-hypertensive therapy is followed by essential decrease in risk of development of dementia of any etiology. Taking into account the fact that vascular dementia often develops at patients who already transferred acute disorders of cerebral circulation at these patients the ABP within 120/80 mm hg is optimum. Taking into account data of evidential medicine purpose of APF inhibitors (perindoprit, lisinopril, etc.) is recommended, it is preferable in combination with diuretics.

Proceeding from features of pharmacokinetics and a pharmacodynamics, lisinopril is priority at AG combination to a diabetes mellitus (EUCLID), at persons with various degree of manifestation of acute hepatocellular insufficiency and chronic diseases of gepatobiliarny system (the only representative of group of APF inhibitors who is recommended for a single dose and at the same time represents the ready dosage form which is not needing additional biotransformation). Metabolic neutrality allows to recommend lisinopril for treatment of patients with manifestations of a metabolic syndrome and obesity (hydrophilic substance). Pharmacological properties of lisinopril are rather in detail studied (7 tests with "intermediate" final points (53 435 patients), and 5 tests with "firm" final points (53 030 patients) that does not concede on scale to researches of representatives of the previous classes - captopril and enalapril, and also surpasses the width of tests of a perindopril, fozinoprit and moeksiprit). On the basis of it it is possible to welcome expansion of the Ukrainian market of lizinopril due to emergence of highly effective and available drugs of the European quality in variety of dosages (Lopril 5, 10, 20 mg) and combinations (Lopril of N 10, 20 mg).

Antagonists of calcium and antagonists of receptors of AT II have independent neuroprotective effect, including prevention of dementia, in addition to decrease in the ABP.

For the purpose of prevention of development of repeated disturbances of cerebral circulation and other cardiovascular complications (a myocardial infarction, etc.) which promote development and progressing of vascular dementia, reception of antithrombocytic drugs is recommended. Drugs of the first row are now: acetylsalicylic acid (ASK) - 50-325 mg of 1 times a day, or клопидогрель - 75 mg of 1 times a day, or ASK combination - 25 mg 2 times a day and the prolonged Dipiridamolum form - 200 mg 2 times a day. Purpose of each of these drugs is individual and depends on portability and existence of risk factors at each patient. At intolerance or inefficiency of ASK reception клопидогреля - 75 mg a day is recommended.

As cerebral heart attacks which are caused by heart diseases (first of all fibrillation of auricles) are the frequent reason of development of vascular dementia, use of peroral anticoagulants (warfarin) under control of the international normalizing relation (INR) is recommended.

Surgical treatment (carotid endarterectomy, angioplasty) is shown to the patients having a critical stenosis of carotid arteries more than 70%, and also atherosclerotic plaques which are an embolism source.

Purpose of statines is recommended to patients with a hypercholesterolemia.

As the basis of vascular dementia is made by cognitive disturbances, for improvement of cognitive functions reception of different groups of drugs is recommended:
- drugs on the basis of Ginkgo Biloba (Tanakanum, a memoplant, etc.);
- antikholinesterazny drugs (амиридин, ривастигмин, Galantaminum, глиатилин, etc.);
- neurotrophic drugs (Cerebrolysinum);
- MAO inhibitors (селегилин);
- nootropa (piracetam, to pramiratseta);
- neuropeptids (solkoserit, Actovegin, lipocerebrinum);
- membrane stabilizing (цитиколин);
- antagonists of NMDA receptors (мемантин);
- antioxidants (vitamins C, E, carotinoids, flavonoids);
- the substances influencing the GAMK system (Aminalonum, Pantogamum, ноофен, etc.);
- vasoactive drugs (ницерголин, Vinpocetine, инстенон, etc.);
- combined (to feza, etc.).

It is necessary to emphasize that drugs which improve a brain blood stream and neyronalny metabolism are more effective if they are appointed at early stages of vascular brain insufficiency when expressiveness of cognitive disturbances does not reach dementia degree yet.

Emergence can demand separate treatment from patients of a depression, uneasiness, hallucinations, psychomotor excitement. In the presence of a depression at patients with dementia preference is given now to inhibitors of the return serotonin reuptake as unlike tricyclic antidepressants they possess smaller anticholinergic side effect, cognitive functions do not oppress.

Reaction to treatment has to be estimated carefully at each patient, considering rather frequent emergence of paradoxical reactions and side effects of therapy. Periodically it is necessary to reconsider treatment, avoiding without the due basis of long administration of drugs, worsening cognitive functions (benzodiazepines, antikonvulsant, neuroleptics, the central cholinolytics, digitalis drugs).

Adequate therapy of the accompanying somatopathies which significantly influence a psychological condition of patients has to be carried out together with other specialists. Psychological support of the patient is important.