Poststroke dementia Vikas Dhikav, MBBS (Rohtak), MD (3-years AIIMS) , PhD (Neurology, PGIMER Delhi), Fellowship Clinical Neuropsychopharmacology, Director, Memory Clinic Delhi & Honorary Professor, ISM-IUK, Bishkek, Kyrgyzstan. www.memoryclinicdelhi.com vikasdhikav@hotmail.com

Post stroke dementia Dementia is one of the major causes of dependency after stroke. Having a stroke doubles the risk of dementia. Leys D et al. Lancet Neurol. 2005;4(11):752-9.

Post Stroke Dementia… Cerebrovascular disease is increasingly recognized as a common cause of cognitive impairment and dementia in later life either alone or in conjunction with other pathologies, most often Alzheimer disease. O'Brien JT. Vascular cognitive impairment. Am J Geriatr Psychiatry. 2006;14(9):724-33.

Vascular cognitive impairment Umbrella term  recognizes the broad spectrum of: Cognitive Behavioral changes associated with vascular pathology O'Brien JT. Am J Geriatr Psychiatry. 2006;14(9):724-33.

Types of VCIs Cortical Subcortical Strategic infarct Hypoperfusion Hemorrhagic Mixed (with AD) type. 

Frequency of post stroke dementia? In a recent study from Northern India, 45% frequency was found. Chaudhari TS et al., J Neurol Sci. 2014;340(1-2):150-8.

Future of post stroke dementia The prevalence of poststroke dementia -defined as any dementia occurring after stroke-is likely to increase in the future. Leys D et al. Lancet Neurol. 2005;4(11):752-9.

History Stroke was recognized as an important cause of dementia ≥1 century ago, Until the 1960s, most cases of dementia were attributed to atherosclerosis. Now cerebrovascular disease is considered to be the second most common cause of dementia Post stroke dementia is one of the rare preventable dementias. Barba R. Stroke. 2000;31(7):1494-501.

Why does VCI occur? Interaction between: Vascular risk factors Hypertension Diabetes Obesity Dyslipidemia Parenchymal brain changes Macro & Micro infarcts White matter changes Alladi S. Annals Ind Acad Neurol 2010; S-104-108.

Patient Related Predisposing factors Increasing age, low education Dependency before stroke & prestroke cognitive decline without dementia Diabetes mellitus , Atrial fibrillation, past myocardial infarction Epileptic seizures Congestive heart failure, hypertension Silent cerebral infarcts & white-matter changes Global and medial-temporal-lobe atrophy Leys D et al. Lancet Neurol. 2005;4(11):752-9.

Stroke Related Predisposing Factors Stroke severity Cause Location Recurrence

Other factors Vascular lesions Alzheimer pathology White-matter changes Or combinations of these.

Overlap? Patients who had a stroke and medial temporal lobe atrophy (MTA) more frequently develop dementia than patients without MTA  Cordoliani-Mackowiak MA. Arch Neurol. 2003;60(4):585-90.

Indian experience Older age at first-ever stroke and cortical atrophy are associated with increased risk for dementia  Das S. Cognitive dysfunction in stroke survivors: a community-based prospective study from Kolkata, India. J Stroke Cerebrovasc Dis. 2013;22(8):1233-42.

Functional outcome? Poor! Barba R. Stroke. 2000;31(7):1494-501; Alladi S. Annals Ind Acad Neurol 2010; S-104-108.

Mortality? Patients with PSD have high mortality rates and are likely to be functionally impaired. Leys D et al., Lancet Neurol. 2005;4(11):752-9.

VCI?/Poststroke?/Vascular? Vascular cognitive impairment (VCI)  entire spectrum of cognitive impairment occurring as a result of cerebrovascular disease. VCI encompasses not only vascular dementia (VaD), but also mixed dementia and vascular cognitive impairment-no dementia (VCI-ND). VCI-ND refers to that subgroup of patients who manifest cognitive deficits resulting from cerebrovascular disease, but do not meet the definition of dementia. 

Main Types Multi-infarct dementia (MID) Subcortical ischaemic vascular disease (SIVD) Strategic infarct subtypes of poststroke VCI 

Post stroke depression Depression was found to be the commonest symptom, irrespective of the subtype or severity of VCI. Gupta M. Behav Neurol. 2014;2014:430128.

BPSD 95% of cases had at least one neuropsychiatric symptom, with depression being the commonest, irrespective of subtype or severity of VCI. Strategic infarct patients had the lowest frequency of all symptoms. Gupta M. Behav Neurol. 2014;2014:430128.

Survival following stroke dementia? Around 3 years! http://www.alz.org/dementia/vascular-dementia-symptoms.asp

Drug treatment No special drug has been approved for vascular dementia. Drugs effective in Alzheimer’s are modestly effective in vascular dementias as well. http://www.alz.org/dementia/vascular-dementia-symptoms.asp

Gaps There remain fundamental gaps in our understanding of pathophysiology, predicting prognosis and outcome, and in therapeutics.  O'Brien JT. Am J Geriatr Psychiatry. 2006;14(9):724-33.

Challenges in post stroke dementias Clinical Trials, mainly in populations selected using currently accepted criteria for vascular dementia, have generally not been encouraging. O'Brien JT. Am J Geriatr Psychiatry. 2006;14(9):724-33.

Management Definitive treatment Control of risk factors e.g. Nimodipine Memantine Cholinesterase inhibitors Control of risk factors e.g. Diabetes Hypertension Hyperlipidemia  

Prevention It is important identify patients at early stages of cognitive impairment, to treat appropriately and prevent progression to frank dementia. Alladi S. Annals Ind Acad Neurol 2010; S-104-108.

Thank you