Subcortical vascular dementia: A review on care and management

Arch. Gerontol. 0167-4943/98/$19.00

Geriatr.

SUBCORTICAL

M.

VASCULAR

NERI,

L.P.

Chair of of Modena

suppl. 6 (1998) 355-362 0 1998 Elsevier Science Ireland

DE

DEMENTIA:

VREESE,

Geriatrics Clinical

C.

Ltd. All right

A REVIEW

FINELLI

and Gerontology, School, Viale V.

and

ON

S.

Department Veneto, 9,

reserved

CARE

355

AND

MANAGEMENT

IACONO

of Internal Medicine, I-41100 Modena, Italy

University

SUMMARY Although vascular dementia and in particular its subcortical subtype, is second only to .Alzheimer’s disease as a basis for dementia, little or no information is available on its care and management. Consequently, this paper attempts to highlight a number of difficulties and pitfalls that informal and formal caregivers have to face, when implementing care and management of elderly individuals with subcortical vascular dementia, who by definition are already “medical patients” before the onset of dementing illness. Different aspects of need for care, the phenomenology of caregiving and care programs are discussed in light of the distinct clinical history, clinical manifestations and treatment between vascular dementia and Alzheimer’s disease. Keywords: ment of

subcortical dementia

vascular

dementia,

care

of

demented

patients,

manage-

INTRODUCTION The will

increasing

present

givers

in

and

provide de,

over

of

coming

years

constitute

80 % of

patients

dementia

a challenge

a burden

home

with

care

on

for

both

society

throughout

requiring

and

most

permanent

informal their

of

the

little

and

care

formal

families,

care-

since

illness

world-wide

in

general,

offer

or

no

families (Mohi-

1993). Recent

reviews

a decade

lable

about

drug

titularly

and

true management

tially

different

Alzheimer

caregiver

from

ber

of

and

implementing

care

The

first of

1996).

problem the

exact

and

subcortical in

present

other

pitfalls

to elaborate

of

OF

SUBCORTICAL

related

to

the of

caring

(VaD)

whose

coping

strategies

critically

be

subcortical VaD

its

dementia dementia,

is par

such

when

care

substanas

comments

neglected

in-

programs This

of

avai-

specific

innovative

and

cannot

of

hope

are

1995).

specific forms

more

data

costs

and Aronson,

reviews that

definite

or

vascular of

paper

management

estimation

efficacy

efforts

a number

and

the

(Lombard0

applied

The

challenges

CHARACTERISTICS

difficulty

with

those

(DAT).

relevant

repeated

include

dementia, Yet,

and

patients

patients should

of 1997).

needs

demented

for

type

et al.,

despite

and

and

treatment

(Rabins

procedures,

caregivers

THE

on

ago care

tervention

Duin,

the

will

than

for

number

of

the

a num designing

VaD. AND

policy

prevalence

NEED of and

FOR subcortical incidence

CARE VaD rates

is

the (Van

356 VaD in

is currently

elderly

developing

of

countries,

yer,

1996).

While

less

common

after

until

of 85 and

rebral

small

quent

etiology

cunar

state;

tend

to the

of

that

of

rence,

it

include

is

(Mendez

et

al.,

1997).

disinhibition, 1994).

mentia

are

often in

1997)

with are

Female diabetes reported

as

whereas

the

ablished

(Corelick,

role

severe

kind

of

risk

by

are

and

VaD

both

or of

cerebral

depression

commonly seen

observed

in

cortical

Clydesdale,

with

or

vessel

al., and

disease.

hyperlipemia,

combination,

large-

Paret

affect,

small

and

atrophy

de-

1994). (Okuzumi

hypotension, in

pershifting

disturbances

pseudobulbar

VaD

alone

set

have

small-vessel

still

been origin,

remain

to

be

est-

1997).

dementias medical

levels

for

concomitant

non-negligible

therapeutic

of

retrieval motor

apathy,

disturbances

hypertension disease,

(with

behavioral

dysarthria,

manifestations

factors

played

by

lo-

occurThese

with

commonly

(Kertesz

the

dysfunction.

impaired

withdrawal

locomotion

Although on

loss

Also

agnosia,

dementia

bilateral

difficulty

VaD.

signs,

chronic

cardiovascular

further,

less

motor

and

VaD

tract

lobe memory

social

prominent

aging,

potential

degenerative

different

frequent

frontal

ex-

syndrome

1995).

and

[la-

often

depending

characterized

and

subcortical

pyramidal

Vermersch,

fre-

lesions

which

attention,

subcortical

the

most

subcortical

multiplicity of

Intrace-

the

a clinical

entity

sustained

and

with

gender, mellitus,

A

in

conjunction

together

incontinence

absent

and

signs

apraxia

of

stroke)

degenerative

change

agitation Aphasia,

be-

controversy

as

produces

inpersistence,

in

of

cohorts

1995).

location

tissue,

Personality

ubiquitous

identified

(bradyphrenia),

and

recent rate

persisting

been

clinical

poor

more

age

Me-

becomes

equivalent in

Hachinski,

1996),

primary

overwhelming

recognition),

are

as

(Codefroy

many

and

VaD

1992),

the

ischemic

al.,

(FLD)

dementia and

(Loeb of

also

and

subcortical

of

DAT

type?)

from

strategic

forms

processes

but

of

Asia

onset

Benson,

has

destroyed

perseveration

(Cummings,

kinsonism

of

the

and

stem

et

of

a high

(Bowler

or

in

1996).

a heterogeneous

by

though

irritability

such

dementia

than

with

other

volume

slowed impaired

formance

and

(Erkinjuntti

marked

Skoog,

mainly

lobes

that

type

DAT;

that

subcortical

predominant

represents

lesions,

the

(microangiopathy) The

in

exceeds

only

definition

changes

lobe

not

common

the

believed

and

matter

most

after

(Cummings

findings

seen

VaD

age

(Aevarsson

VaD.

frontal

was

shown

clinical

second

VaD

(including

disease

white

frontal

cation

VaD

and

vessel

subcortical

more

and

etiology

to

in

of

contradictory

its

it

have

88 years

Similar about

similar

years

the

countries of

recently

75

DAT

to be

Western incidence

studies

incidence tween

the the

population-based

or

considered

habitants

is

point that

the

differentiating former

(cardiovascular intervention

of care

and

or

subcortical

is commonly metabolic)

on

a regular

management.

The

preceded diseases,

basis. first

VaD

This regards

by

from other

which event the

other more

require is

process

or some

reflected of

at recog-

357 nizing

a

family

new

condition.

erroneously

the

unlike in

As

matter

with

the

patients,

tends

to

with

side

metabolic

diffuse

ageism

of

(Williamson

gait

subcortical

disorders

VaD.

aging-associated

rather

All nostic tion

of

vior

breaks

the

but clinical

on

earliest

stage

affecting

prognosis

1996),

the

practitioner by et

the

al.,

the

Finally,

and

1997).

appearance in

keeping

symptoms

as

incontinence, for

fa-

cardiovas-

facilitate

with

to biased

in

slowed

characteterms

of

a

mere

symptomatology. role of

not care

when

face

the

behavior family

general

such

not

a

need

to

of

enables

or

accounted

only

attitude

caregiving

reported

1996).

be

play

(eventually

and

the

may

the

(Harwood

or

to

or

hypertension,

a disease-specific

in

picture

Fried,

likely

of

also

through)

effects

are

conditions

procedures

and

mood

treating

provoke

Jeste,

associated

than

aforementioned

to and

the

treatment

for

known

(Eastham

by symptoms

drug

and

Second,

diagnosis

used

are

cognition,

interpret

a current usually

disorders

processes,

ristic

of

drugs

disturbances

a still

tal

effects the

in

patient

maladjustment.

interfere

of

the

changes

also

fact,

both

psychological

DAT

behavioral

thought

subtle

to

may

of

and

of

or

that

with

terms

cular

likely

new,

disease

self-reports

mily

is

ascribe

pre-existing

who,

It

it.

a

This

disease

since

institution

of

only in

in of

“strange obviously

its

identification

efficient

disease

leads

diag-

both

or

may

an

postponing

terms

presenta-

unusual”

beha-

have

detrimenat

the

secondary

very

preventive

therapy.

SPECIFIC

ASPECTS The

from

the

change may to

of

since

also

be

cognitively

It

to

and

guilt.

need

a

of

a

perceived

multifaceted

condition

outcome

of

care.

may caregivers

process at

least

of the

the

education

available

who

1995).

VaD

has

In

with the

a

change

woman,

increase

individual and

from

with

that

result

of a

the

ad-

advancing patient

ineffective

will

care

or if

sensation those

information professional

[Diwan

of

VaD of

even

carer’s

particular

and

incipient

appearance

treatable, the

in and

services

only

role

al.,

shift

1996).

exaggerate and

a et

for

not

The

usually

to

to

implies

1996).

caregiver

elderly

moves

al.,

continues

al.,

members

This

et

(Litvin

patient, as

which

caregivers.

caregiver,

VaD

the

family

members

primary et

that

Consequently,

covering

of the

medical

situation

a hopeless

main

(Boucher

strictly be

of (Albert

family

that

emphasized

could

that

the

incidence

likely

a

terms,

disease,

and

be

disease

other

for different

impaired

considered

menting

1995)

rate very

should

usually

to approach

between

the

becomes

helpers

problems

time

it

dementing

psychological

serious her

age.

in

of

CAREGIVING of

occasional

terms

provoke divide

THE

Awareness

role in

dition,

OF

carer.

de-

help. not

Said curable

of

burden

VaD

patients,

and

Moriarty,

reference

is

the

points

358 (i)

Available

services

it

is easily

predictable

VaD. to

care,

as

cess

of

sional

, to

pointed

monitoring

is attributed

and

contacting In

and

Other

nologists

ing

such

of

the

cycle

strain

for

episodic DAT

more

the

early

stage.

drug

shown

caregiver’s a higher To

or

sum than

of

up, that

et

the of

diabetic

but

and

1996).

et patient

presenting

also

a more their of

episodic

frequent

social

a

suggests multifactorial

drug

regimens,

perceiving VaD in

changes

medical VaD)

admittance

of

Additio-

evidence

in

and

than

memory

interpretation

of

with

behavior

VaD,

subcortical the

antero-

management

from

effects

as of

VaD

patients.

difficulties

(1996).

al.

and

complex

Finally,

detrimental

as in

of

of

derives managing

psychological

than

assessment cognitive

al., the

Cefalu

abnormal

rate

in problems

to

by

burden, mortality

mainly

difficulties

such

DAT

bulk

a visuch

sources

a correct

a growing

advanced

powerful

care of

and

more

profound

hamper

emo-

a pre-exist-

syndrome

severity

that

could

Finally,

behavioral

less

be foand

determines

VaD

renders

than

symptoms

institutionalization

a cardiopathic

ing

problematic

prone

frequency

and

the

more

increasing

1997)

VaD

(Rockwood

recently

with

should

of

deficits

be

endocri-

neurovegetative in

the be

to

the

diagnosis

cognitive

care

dementia

found

be

or

obviously

could

canonical

al.,

more the

profiles,

therapy

and

et

on

reduced

of

the

care

on

also

or

control

been

VaD only

which

well

made

infrequently

1997),

motor

including

particularly

not

condibetween

management.

subcortical

but

clinical

cardiologists

main

locating

alliance very

who as

not

the in

new

could

and

components

treatment.

of

frailty,

of

al.,

However,

even of

that

Many

impaired

[Bowler

in

is interrupted

has

be

As

(e.g.,

1995),

other

process

clinical

a higher

al.,

than

of

complex

rather

and

VaD

of

ings.

et

risk.

fluctuation

condition

to

(Hill

which

efficacy

outcome

disease,

amnesia, its

the

that

DAT, the

caregiver

advanced

the

in of

et

latter

care

stage

[Rockwood

accelerates

nally,

seem

hypertension

for

stressing

increasing

the

in

decline

of

as

change

grade in

is worth

disease of

personality

It

the

a pro-

a profes-

which

a solid

geriatrician

candidates

to in

control

from

obstacles

on

such

from

is,

attributed

manage

The

subcortical

move

a person,

to

of

That

is

is based

the

will

encounter

specialists

unlike

disturbances

disease

cious

care:

able

or

role

helping

professionals.

consulted

case

(1995).

could

treatment

the

services

main

and

neurologist

earliest

disorders.

the

services

to become of

for

carers

of the care

the

very

tional-affective

stages

and core

unlikely

the

which

The

in

Pallett-Hehn

monitoring

health

Outcome

from

motor

in

persons:

request

and

family.

previously

are (ii)

cuse

the

both

the

practitioner,

VaD.

that Baker

professionals

family

general of

of to the

particular,

patient,

by

reference

a disease,

a process

role

tion.

out

and

patients care

dementia

settpatient

portrays

not

depression, to

the

only

increas-

nursing

homes

counterparts.

functional functioning

skills

and has

been

behavioral proposed

competence as

a more

359

suitable

criterion

theoretical

to

problems

The action

patient.

(Hades

to

at

disorders,

1995)

by

awareness

of

derives

from

explain

why

higher to

subcortical

particular,

for observed

concomitant

illness

in

conjunction

in

the

has

been

When

this

frontal

aspontaneity

patients

with

their

self-per-

may

be

This

verbal

true,

anterorolandic

patients

to

likely

preserved

adynamism

subcortical

observed

of

VaD

holds of

symptomatology.

or

often

interand

in

claim effects

VaD

a tendency

lobes is

of

general,

described

emotional

aphasic

terms

for

comment.

insight

depressive with

in

1992).

subcortical

appropriate

in

deserve

in in

more

patient,

devastating

reactions

is

conditions

and

illness

that

latter

opposite

Benson,

risk

often

lesions

in

and

an

verbal

two

the

caregivers

preserved

Catastrophic

exacerbated

which

connections,

already

in

the

may

early

stages

of

VaD.

(ii)

Conversely,

sphere

are

subcortical

the

crucial

Therefore,

since

VaD or

frequent

clinical

and or

activities,

and

et

1996),

can

al.,

of

are one

thought.

As

can

since to

even

jeopardise

in

the

in

these

to

or

might the

cerebral of

focal

may

prevent

for

of a person

important use

the

cognitive

loss

in

dangerous

or

be

stroke

have the

to maintain

in

could

cerebral

VaD

et

unawareness

illness

right-sided

phenomena

(Ott

lesioned

that

dementing

hemi-

illness

indirectly

suspect

participation

ability

right

awareness

subcortical

compensate

lead

and

directly to

anosodiaphoria

strategies

They

lobes

maintenance lobes

implications

induced

consequences.

frontal

(anosodiaphoria)

or

practical

generated

the

traditionally

anosognosia

the

frontal

indifference

than

of

for

(Erkinjuntti

(anosognosia)

patients,

integrity

considered

1996).

more

al.,

similar

brain-damage.

al.,

formal

(Cummings

are

since

VaD,

and

better

DAT

patients

ceived

et

Relatively

compared

needs

subcortical

informal

communication

VaD

care 1996).

In

between

(i)

assess (Jorm,

of

self-

and

their

unrealistic

a higher

level

of

self-care. [iii)

Subcortical

vascular

often

associated

with

ties,

which

potentially

may

sphere-specific found such

to as

al.,

1994)

but

no

subcortical

speech,

answers,

Some

comodation

create

evidence

problems

to

dementia

and

general

specific VaD

study patients.

in

the

the has

occurrence been

thus

cerebral

in

are

and

or

reported

the

acts

[Cummings the

oral

problem

of

have

ideative (De

of

been use,

or

Vreese

verbal et

speech

spouses and

hemi-

discourse

care-oriented case

also abili-

Right

illnesses of

digress,

spontaneous in

addressed

management.

speech

are

communication

dementing

wander

of

hemisphere

verbal

aspects

indirect

described

far

in

in care

to with

suggestions has

right

pragmatic

proneness

difficulties on

the

disorders

alteration

tangential

in

disturbances

language-related determine

perseverative 1996).

lesions

underestimated

al., ac-

(Kemper Benson,

communication

et 1992), in

360 DEMENTIA

CARE

As are

out

principally

the

of

ted

treatment

or

described

cognitive

level

refore,

not

1997).

This

true

that

the

only

which in

the

medical,

To

to

1996).

because black

obtain

box

to

of

of

which

terms

is

there

this

likely

is

However, than et

indepth

al.,

under-

ascribable

no

need

to and

VaD

DAT

the

disrela-

patients

patients, 1996)

have

when

and

the

need,

the-

an from

involved be

extremely

dementias

and

Bowler of

Indeed,

may

given

behavioral

the

holds

is

intuitively

dyad

in

which

work

as

well

of

true

the

for

al.,

disease

the for

aforementioned

profiles

same

et the

it

not

dif-

neuropsycholo-

1996;

understanding

1995)

complex

of

even

functional

a patient-carer

The

more

identify

Finkel,

VaD,

carer.

intervention would

for

Tartanj,

and

absence

to

interventions.

subcortical

the

of

a more

action

present

indications the

of

disturbances

attempt

1994;

and

has

an

al.,

therapeutical

could in

VaD,

that

(Cefalu

in

et

(LaBarge

profile

conclude,

difficult

utic

also

lead

patient

which

methodologies

reasons

behavioral 1996).

been

neuropsychological

psychological

management,

authors

problems

there

course

DAT

to

equated

but

of

particular pure

addressed

(Eriksson,

has

could

spectrum

several

studying

behavioral was

intervention

the

programs.

etiology,

avenue

a

in

in

of

some

when

(Hadjiastavropoulus

wider

rences

performance

recent

has

dyad

of

of

VaD more

years

profiles

patient

approaches

having

in

gical

a

care

care

fering

and

statement and

as

reproducible One

specifically

DAT

differentiated Only

[1996), DAT.

programs

explicit

between

been

O’Rourke toward

care

repeated

tinguish

by

targeted

development to

PROGRAMS

pointed

patient

or

in

pharmacological

choices.

effort

in

this

more

organized

is a blending difficult

direction, trials of

to

it

will

(Rovner

strategies,

replicate

remain et

al.,

a therapein

a

diffe-

a

consistent

manner.

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