Vascular Dementia

What Vascular Dementia is

Vascular Dementia is a syndrome of cognitive impairment caused by reduced blood flow to the brain or by injury to brain tissue from cerebrovascular events. The cognitive picture varies according to which parts of the brain are affected and over what timescale. Two patterns are most commonly seen:

• Post-stroke Vascular Dementia, where cognitive symptoms begin abruptly after a stroke or transient ischaemic attack and either persist or partly recover.
• Subcortical Vascular Dementia, where progressive Small Vessel Disease produces a more gradual decline in attention, processing speed and executive function, sometimes with mild gait change.

Vascular Dementia accounts for around 15 per cent of dementia in older adults as a pure entity, but co-occurs with Alzheimer's Disease in another 20 to 30 per cent of cases, producing Mixed Alzheimer's and Vascular Dementia.

How it presents

Compared with Alzheimer's Disease, the cognitive profile tends to be:

• Slower thinking and reduced attention rather than dense memory loss;
• Executive difficulties: planning, multitasking, mental flexibility;
• Word-finding pauses with relative preservation of recognition memory;
• Mood change, apathy and emotional lability, sometimes early;
• Mild gait changes ("subcortical" gait, shuffling) and reduced balance;
• A stepwise decline pattern after vascular events, with plateaus in between, or a gradual decline if the underlying mechanism is chronic Small Vessel Disease.

How it is diagnosed

NICE NG97 and the international VICCCS framework form the basis of UK practice. Diagnosis rests on three pillars:

• A cognitive decline severe enough to interfere with day-to-day life (the functional criterion that distinguishes dementia from Mild Cognitive Impairment);
• Imaging evidence of Cerebrovascular Disease judged sufficient to explain the cognitive picture: Small Vessel Disease (Fazekas grade 2 or 3 on Magnetic Resonance Imaging), lacunes, or larger infarcts;
• A plausible temporal link between vascular injury and cognitive change.

Investigations follow the standard memory work-up: Addenbrooke's Cognitive Examination (ACE-III), blood tests to exclude reversible contributors, an Electrocardiogram (looking specifically for Atrial Fibrillation), and a structural Magnetic Resonance Imaging brain scan. Carotid imaging and echocardiography may be added when relevant.

What the imaging shows

Typical Magnetic Resonance Imaging findings include:

• White matter hyperintensities (Fazekas grade 2 to 3);
• Lacunes (small old infarcts under 1.5 cm);
• Larger chronic infarcts in cortical or strategic subcortical regions;
• Variable cortical atrophy, often less than in pure Alzheimer's Disease.

In our 476-letter cohort, the mean Fazekas grade in Vascular Dementia was 2.23, compared with 1.12 in pure Alzheimer's Disease. Around one in five Vascular Dementia patients in the cohort were assessed using Computed Tomography rather than Magnetic Resonance Imaging.

How it is treated

Vascular risk reduction is the core treatment

Tight control of blood pressure, lipids, glucose, smoking and alcohol slows progression and reduces the risk of further vascular events. See our vascular risk reduction page for the full action plan. The single most impactful action is generally bringing blood pressure into target range, supported by lifestyle change.

Antithrombotic medication where indicated

Anticoagulation (e.g. Apixaban) is recommended for Atrial Fibrillation per NICE NG196. Antiplatelet treatment (e.g. Aspirin or Clopidogrel) is appropriate after stroke or transient ischaemic attack per NICE NG128. Routine prescription of Aspirin "for Vascular Dementia" is not recommended.

Cholinesterase inhibitors

NICE TA217 does not recommend Cholinesterase Inhibitors for pure Vascular Dementia. They are recommended for the Alzheimer's component of Mixed Alzheimer's and Vascular Dementia. Where there is diagnostic uncertainty between the two, a trial may be considered, with review at three months.

Lifestyle and rehabilitation

Regular exercise, a Mediterranean Diet pattern, treatment of depression and Obstructive Sleep Apnoea, and addressing hearing loss all support cognition. Speech and language therapy, occupational therapy and physiotherapy support specific deficits where present.

What course it takes

The trajectory varies. People with isolated post-stroke deficits often plateau and may improve over the first year. People with progressive Small Vessel Disease typically decline gradually, with occasional steps after new vascular events. Aggressive vascular risk control can dramatically alter the trajectory.

Where to get assessed

NHS memory clinics and stroke services provide assessment for most people. If you would value prompt assessment, structured ICD-11 aligned reporting, Magnetic Resonance Imaging, Electrocardiogram and a clear plan for vascular risk reduction in one place, The Dementia Service is the leading UK Private Memory Clinic. The structured letter is shared with your GP so vascular follow-up continues seamlessly under shared care.