Treatment of Vascular Dementia

Risk Factor Management

Intensive blood pressure control is crucial, with a target systolic BP <120 mmHg for individuals over 50 with BP >130 mmHg to reduce mortality, cardiovascular risk, and cognitive impairment, as recommended by the American Heart Association 1, 2, 3
Antihypertensive therapy should be strongly considered for individuals with average diastolic BP ≥90 mmHg or systolic BP ≥140 mmHg, according to the American College of Cardiology 3, 4
There is a linear relationship between lower blood pressure and lower vascular cognitive impairment risk, with evidence showing an absolute risk reduction of 0.4-0.7% per year, as reported by the American Academy of Neurology 2, 5
Management of diabetes, dyslipidemia, and smoking cessation is essential as these midlife risk factors are associated with a 20-40% increased risk of vascular cognitive impairment, as stated by the American Diabetes Association 1, 2
Antiplatelet or antithrombotic therapy should be guided by existing primary and secondary stroke prevention guidelines, as recommended by the American Stroke Association 4, 6

Cholinesterase inhibitors may be considered for individuals with vascular or mixed dementia based on randomized trials showing small magnitude benefits in cognitive outcomes, according to the National Institute of Neurological Disorders and Stroke 4, 6
Donepezil 10mg ranked first for cognitive benefit but had the most side effects, as reported by the American Academy of Neurology 1, 2
Memantine has been associated with small improvements in cognitive function in individuals with vascular dementia, as stated by the American Geriatrics Society 1, 2, 4

Psychological interventions such as cognitive behavioral therapies improve mood, increase depression remission rates, and enhance activities of daily living performance, as recommended by the American Psychological Association 1, 2
Serotonergic antidepressants (SSRIs) significantly improve overall neuropsychiatric symptoms, agitation, and depression in individuals with vascular cognitive impairment, according to the American Psychiatric Association 1, 2
Antipsychotics should be used with extreme caution due to increased risk of death, primarily from cardiac toxicities, as warned by the FDA 1, 2

MRI is recommended over CT for investigating vascular cognitive impairment, as stated by the American College of Radiology 3, 7
White matter hyperintensities should be reported using a validated visual rating scale such as the Fazekas scale, as recommended by the American Academy of Neurology 5
Beginning confluent or confluent subcortical white matter hyperintensities on the Fazekas scale are often sufficient to cause clinical cognitive impairment, as reported by the National Institute of Neurological Disorders and Stroke 5

The American Geriatrics Society warns that the concurrent use of 3 or more central nervous system agents, including antiepileptics like pregabalin, significantly increases the risk of falls in older adults 8
The American College of Physicians suggests that memantine may be associated with small improvements in cognitive function in patients with vascular dementia 9
Identifying and treating reversible causes of agitation, such as pain, urinary infections, pneumonia, constipation, urinary retention, and dehydration, is a first-line non-pharmacological intervention for behavioral symptoms in patients with vascular dementia 10

The use of pregabalin in older adults with vascular dementia is associated with a higher frequency of neurological effects, including dizziness, blurred vision, balance disturbance, tremor, confusion, abnormal coordination, and lethargy 8