Association between cognitive impairment and cerebrovascular disease Hege Ihle-Hansen MD, phd Vestre Viken HT, Bærum Hospital Norway

Outline Introduction Challenges Future directions Cognition Cerebrovascular disease Challenges Link between vascular disease and cognition Impact of vascular risk factors and treatment of vascular disease in older age Pathophysiology Future directions

What do we need to know Cardio vascular disease (CVD) and dementia shear many risk factors Many risk factors are modifiable Early identification and risk control may preserve cognitive function

Introduction

Neurocognitive disorders DSM-5 Ability to think Clinical diagnosis Contiuum Normal Mild neurocognitive disorder Major neuricognitive disorder Different subtypes or causes

Cerebrovascular disease

Atherosclerosis and cognition

Link between vascular disease and cognition Challenges Link between vascular disease and cognition

Dementia after stroke 10% av pasienter innlagt med første hjerneslag har demens før hjerneslag. 10% vil få demens som følge av hjerneslaget. Av alle innlagte slagpasienter vil ca 25% ha demens 1 år etter hjerneslaget. Høyest andel ved tilbakevendende hjerneslag. Videre ser man en gradvis økende prosentandel som utvikler demens. Post-stroke dementia (PSD) or post-stroke cognitive impairment (PSCI) Pendlebury, Int J Stroke, 2012

Cerebral White Matter Lesions and the Risk of Dementia Severity of white matter lesions (WML) is divided into 3 categories based on the distribution of periventricular WML scores. The risk of dementia is expressed as age- and sex-adjusted hazard ratios. The number of dementia cases and total number of participants, respectively, in consecutive periventricular WML severity categories were 16 and 749 (grade 0-3), 18 and 261 (grade >3-6), 11 and 66 (grade >6-9), and in consecutive subcortical WML severity categories 24 and 763 (0-1 mL), 10 and 244 (>1-6 mL), and 10 and 65 (>6-29.5 mL). Arch Neurol. 2004;61(10):1531-1534.

Kivipelto, Lancet Neurol 2006

Challenges Impact of vascular risk factors and treatment of vascular disease in older age

Risk factors for stroke High blood pressure  Cigarette smoking  Diabetes mellitus  Carotid or other artery disease  Atrial fibrillation  Other heart disease  High blood cholesterol  Poor diet  Physical inactivity and obesity  Stress

Source: Misfinancing global health: a case for transparency in disbursements and decision making. The Lancet D Sridhar, R Batniji 27 September 2008, 372: 9644, 1185 - 1191

Is it of clinical importance? Barnes, Lancet Neurol 2011

Challenges Pathophysiology

Vascular risk Vascular risk factors leads to angiopahty leading to cognitive decline macrovascular micro vascular Induce inflammation Interact with AD The vascular risk can directly increase the suscetibility to Alzheimer’s disease

Possible interactions between vascular and degenerative disease Loss of neurons Morbus Alzheimers Amyloid-β Cerebrovascular disease Ischemia Dementia ↑secretase activity ↓Aβ clearance Vascular Aβ deposit ↑tau phosphorylation Vasoconstriction

We aimed to explore the association between total-tau and brain atrophy, measured as ventricular volume and total brain volume, one year post-stroke

Future directions

Acute stroke treatment

Different trajectories Pet – amyloid avleiring 10 år før symptomer på kognitiv svikt Kartelgge alle slagpasienter med spinalpunkjson eller PET ? Inflammasjonen – vaskulære risikofakorer ? Gener? Mulige behmål – antiinflammatoriske legemidler ? Thiel et al Stroke. 2014;45:2825-2829

The Seven ways of life Be smart, exercise your heart: exercise effects on brain and cognition

Global targets for NCDs To be attained by 2025

Association between cognitive impairment and cerebrovascular disease Researsch Early diagnosis Prediction Prevention Treatment Risk factors Physical and cognitive training Succussfull aging? Expectations Multifactorial risk