220 Vascular Dementia (formerly Multi-Infarct Dementia) (290.4x)

DSM-IV-TR criteria

• A. The development of multi cognitive deficits manifested by both:
  • 1) memory impairment (impaired ability to learn new information or to recall previously learned information) and
  • 2) one (or more) of the following cognitive disturbances:
    • (a) Aphasia (language disturbance)
    • (b) Apraxia (impaired ability to carry out motor activities despite intact motor function)
    • (c) Agnosia (failure to recognize or identify objects despite intact sensory function)
    • (d) disturbance in executive functioning (i.e., planning, organizing, sequencing, abstracting)
• B. The cognitive deficits in Criteria A1 and A2 each cause significant impairment in social or occupational functioning and represent a significant decline from a previous level of functioning.
• C. 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.
• D. The deficits do not occur exclusively during the course of a delirium
• Code based on predominant features:
  • 290.41 With Delirium: if delirium is superimposed on the dementia
  • 290.42 With Delusions: if delusions are the predominant feature
  • 290.43 With Depressed Mood: if depressed mood (including presentations that meet full symptom criteria for a Major Depressive Episode) is the predominant feature. A separate diagnosis of Mood Disorder Due to a General Medical Condition is not given.
  • 290.40 Uncomplicated: if none of the above predominates in the current clinical presentation
• Specify if:
  • With Behavioral Disturbance
  • *Coding note: Also cerebrovascular condition on Axis III**

Associated Features

• Associated descriptive features and mental disorders.
• Associated laboratory findings. The extent of central nervous system lesions detected by CT and MRI in Vascular Dementia typically exceeds in the extent of changes detected in the brains of healthy elderly persons (e.g., periventricular and white matter hyperintensities noted on MRI scans). Lesions often appear in both white matter and gray matter structures, including subcortical regions and nuclei. Evidence of old infarctions (e.g., focal atrophy) may be detected, as well as findings of more recent laboratory evidence of associated cardiac and systemic vascular conditions (e.g., ECG abnormalities, laboratory evidence of renal failure).
• Associated physical examination findings and general medical conditions. Common neurological signs (e.g., abnormal reflexes, weakness of an extremity, gait disturbance) are discussed in the “Diagnostic Features” section. There is often evidence of long-standing arterial hypertension (e.g., funduscopic abnormalities, enlarged heart), valvular heart disease (e.g., abnormal heart sounds), or extracranial vascular disease that may be sources of cerebral emboli. A single stroke may cause a relatively circumscribed change in mental state (e.g., an aphasia following damage to the left hemisphere, or an amnestic disorder from infarction in the distribution of the posterior cerebral arteries), but generally does not cause Vascular Dementia, which typically results from the occurrence of multiple strokes, usually in different times

Gender and cultural differences in presentation

In most countries, vascular dementia is a much less common form of dementia than AD.

This is true in North America and Europe, but is not so in Japan, where it is more common than AD. Overall, vascular dementia is the second most common form of dementia, after AD.

About 10–20% of patients who experience dementia have the vascular form of the disorder.

The difference in prevalence in different countries may result from different lifestyle factors rooted in the culture.

Vascular dementia is more common in men than in women, which may be because men are more likely than women to suffer from strokes.

Vascular dementia becomes increasingly prevalent as people grow older.

The number of people affected by vascular dementia rises dramatically during and after the sixth decade. Vascular dementia usually occurs at a younger age than AD.

The onset of Vascular Dementia is typically earlier than that of Dementia of the Alzheimer’s Type.

Epidemiology

Vascular Dementia is reportedly much less common than Dementia of the Alzheimer’s Type

Etiology

See p. 152 for a general discussion of the course of dementia.

The onset of Vascular Dementia of 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. Usually the pattern if deficits is “patchy,” depending on which regions of the brain have been destroyed.

Certain cognitive functions may be affected early, whereas others remain relatively unimpaired.

Early treatment of hypertension and vascular disease may prevent further progression.

*Vascular dementia is thought to be caused by strokes that interfere with blood flow to the brain and is sometimes called multi-infarct dementia.

Links

• Journal article: Cognitive functioning in Alzheimer’s and Vascular Dementia