Psychological Disorders: Multi-Infarct Dementia
American
Description
The development of multiple cognitive deficits manifested by both:
Memory impairment (impaired ability to learn new information or to
recall previously learned information)
One (or more) of the following cognitive disturbances:
Aphasia (language disturbance)
Apraxia (impaired ability to carry out motor activities despite intact
motor function)
Agnosia (failure to recognize or identify objects despite intact sensory
function)
Disturbance in executive functioning (i.e., planning, organizing,
sequencing, abstracting)
The cognitive deficits (above) cause significant impairment in social
or occupational functioning and represent a significant decline from
a previous level of functioning
Focal neurological signs and symptoms (e.g., exaggeration of deep
tendon reflexes, extensor plantar response, pseudobulbar palsy, gait
abnormalities, weakness of an extremity) or laboratory evidence indicative
of cerebrovascular disease (e.g., multiple infarctions involving cortex
and underlying white matter) that are judged to be etiologically related
to the disturbance.
The cognitive deficits do not occur exclusively during the course
of a delirium.
Problem
Areas (When Initially Diagnosed)
Socio-Economic:
Moderately impaired homemaking
Moderately impaired money management
Requires voluntary institutional care (placement in supervised residence
or nursing home)
Depression:
Significant loss of interest and motivation
Significant problem with concentration
Intellectual Impairment:
Significant problem with memory or learning
Significant decrease in speech and movement
Significant problem with grooming and hygiene
Significant confusion as to date, place, or person
Onset
and Course
The onset of Vascular Dementia is typically earlier than that of Alzheimer's
Dementia, but much less common.
Onset is typically abrupt, followed by a stepwise and fluctuating
course that is characterized by rapid changes in functioning rather
than slow progression.
The course, however, may be highly variable, and an insidious onset
with gradual decline is also encountered.
European
Description
Vascular (formerly arteriosclerotic) dementia, which includes multi-infarct
dementia, is distinguished from dementia in Alzheimer's disease by
its history of onset, clinical features, and subsequent course. Typically,
there is a history of transient ischaemic attacks with brief impairment
of consciousness, fleeting pareses, or visual loss. The dementia may
also follow a succession of acute cerebrovascular accidents or, less
commonly, a single major stroke. Some impairment of memory and thinking
then becomes apparent. Onset, which is usually in later life, can
be abrupt, following one particular ischaemic episode, or there may
be more gradual emergence. The dementia is usually the result of infarction
of the brain due to vascular diseases, including hypertensive cerebrovascular
disease. The infarcts are usually small but cumulative in their effect.
Diagnostic
Guidelines
The diagnosis presupposes the presence of a dementia as described
above. Impairment of cognitive function is commonly uneven, so that
there may be memory loss, intellectual impairment, and focal neurological
signs. Insight and judgement may be relatively well preserved. An
abrupt onset or a stepwise deterioration, as well as the presence
of focal neurological signs and symptoms, increases the probability
of the diagnosis; in some cases, confirmation can be provided only
by computerized axial tomography or, ultimately, neuropathological
examination.
Associated
features are: hypertension, carotid bruit, emotional lability with
transient depressive mood, weeping or explosive laughter, and transient
episodes of clouded consciousness or delirium, often provoked by further
infarction. Personality is believed to be relatively well preserved,
but personality changes may be evident in a proportion of cases with
apathy, disinhibition, or accentuation of previous traits such as
egocentricity, paranoid attitudes, or irritability.
Includes:
* arteriosclerotic dementia
Differential
Diagnosis
Consider: delirium (F05.-); other dementia, particularly in Alzheimer's
disease (F00.-); mood [affective] disorders (F30-F39); mild or moderate
mental retardation (F70-F71); subdural haemorrhage (traumatic (S06.5),
nontraumatic (I62.0)).
Vascular
dementia may coexist with dementia in Alzheimer's disease (to be coded
F00.2), as when evidence of a vascular episode is superimposed on
a clinical picture and history suggesting Alzheimer's disease.
F01.1
Vascular Dementia Of Acute Onset
Usually develops rapidly after a succession of strokes from cerebrovascular
thrombosis, embolism, or haemorrhage. In rare cases, a single large
infarction may be the cause.
F01.1
Multi-Infarct Dementia
This is more gradual in onset than the acute form, following a number
of minor ischaemic episodes which produce an accumulation of infarcts
in the cerebral parenchyma.
Includes:
* predominantly cortical dementia
F01.2
Subcortical Vascular Dementia
There may be a history of hypertension and foci of ischaemic destruction
in the deep white matter of the cerebral hemispheres, which can be
suspected on clinical grounds and demonstrated on computerized axial
tomography scans. The cerebral cortex is usually preserved and this
contrasts with the clinical picture, which may closely resemble that
of dementia in Alzheimer's disease. (Where diffuse demyelination of
white matter can be demonstrated, the term "Binswanger's encephalopathy"
may be used.)
F01.3
Mixed Cortical And Subcortical Vascular Dementia
Mixed cortical and subcortical components of the vascular dementia
may be suspected from the clinical features, the results of investigations
(including autopsy), or both.