Geriatric Psychiatry Self Assessment Program Chapter 15 Vascular Dementia

Geriatric Psychiatry Assessment Program Chapter 15 Vascular Dementia 1

1. A patient with vascular dementia (VaD) is more likely than an Alzheimer's disease (AD) patient to have difficulty with which one of the following?

a. Anomia b. Sentence repetition c. Impaired selective or divided attention d. Story recall e. Short term memory

Rationale: Difficulty with tests of memory and language (e.g., naming, story recall, and sentence repetition indicate an impairment of anterograde memory (new learning ability), which is characteristic of AD. Cognitive profiles of patients with vascular cognitive impairment are more likely to have difficulty with selective or divided attention (e.g., the ability to split attention between more than one task). Reduced verbal fluency, and cognitive slowing with preservation of cued memory and depression, irritability and lack of initiative are also common.

The recommended option is c. ______Lyketsos CG. Chapter 13. Dementia and Milder Cognitive Syndromes. In: Blazer DG, Steffens DC, eds. The American Psychiatric Publishing Textbook of Geriatric Psychiatry. Fourth edition. Washington, DC: American Psychiatric Publishing, Inc; 2009. pp 243 - 260

Craft S, Cholerton B, Reger M. Chapter 62. Cognitive Changes Associated with Normal and Pathological Aging. In: Kane RL, Ouslander JG, Abrass IB, Resnick, B. eds. Essentials of Clinical Geriatrics, seventh edition. McGraw-Hill Education LLC, New York; 2013.

2. Which one of the following impairments should be present for a diagnosis of vascular dementia (VaD)?

a. Ataxia b. Emotional lability c. Focal neurologic deficit d. Ophthalmoplegia e. Parkinsonism

Rationale: The DSM 4TR, DSM -5 and the NINDS - AREN criteria all require the presence of a decline in cognitive performance from a previously higher level, memory impairment and evidence of cerebrovascular disease. Geriatric Psychiatry Assessment Program Chapter 15 Vascular Dementia 2

The DSM-5 characterizes Neurocognitive Disorders as inclusive of multiple subtypes, including, vascular disease. Criteria for vascular disease includes evidence of cerebrovascular disease and exclusion of other cognitive disorders. The DSM - 5 further characterizes neurocognitive disorders as major or minor. In Major Neurocognitive Disorder, deficits interfere with independence in everyday activities. For a diagnosis of Minor Neurocognitive Disorder, deficits are troubling but do not interfere with the capacity for independence in daily activities.

The recommended option is c. ______American Psychiatric Association. Neurocognitive Disorders. In: American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders DSM - V. Washington, DC: American Psychiatric Press; 2013: 591- 643.

Erkinjuntti T. Clinical criteria for vascular dementia: the NINDS-AIREN criteria. Dementia. 1994; 5 (3-4): 189-192.

Craft S, Cholerton B, Reger M. Chapter 62. Cognitive Changes Associated with Normal and Pathological Aging. In: Kane RL, Ouslander JG, Abrass IB, Resnick, B. eds. Essentials of Clinical Geriatrics, seventh edition. McGraw-Hill Education LLC, New York; 2013.

3. Which of the following is NOT an etiologic subtype of vascular dementia:

a. Single or multiple infarcts of various sizes b. MAPT c. Small vessel disease d. Hypoperfusion e. hemorrhage

Rationale: The NINDS -AIREN criteria list six vascular etiological subtypes of vascular dementia: multiple large infarcts, strategic single infarcts, small vessel disease, hypoperfusion, hemorrhage or miscellaneous vascular insult. It is likely that dementia due to small vessel disease is the most common form. Mutations in MAPT, or, microtubule-associated protein tau is defective in a rare form of familial frontal temporal lobar degeneration (FTLD).

The recommended option is b. ______

Craft S, Cholerton B, Reger M. Chapter 62. Cognitive Changes Associated with Normal and Pathological Aging. In: Kane RL, Ouslander JG, Abrass IB, Resnick, B. eds. Essentials of Clinical Geriatrics, seventh edition. McGraw-Hill Education LLC, New York; 2013. Geriatric Psychiatry Assessment Program Chapter 15 Vascular Dementia 3

Sweet RA, Wilkosz PA. Chapter 6. Genetics. In: Blazer DG, Steffens DC, eds. The American Psychiatric Publishing Textbook of Geriatric Psychiatry. Fourth edition. Washington, DC: American Psychiatric Publishing, Inc; 2009. pp 125.

Erkinjuntti T. Clinical criteria for vascular dementia: the NINDS-AIREN criteria. Dementia. 1994; 5 (3-4): 189-192.

4. Vascular Cognitive Impairment (VCI) is characterized by all of the following statements EXCEPT: a. attentional and executive impairment and depression b. prion disease c. cortical, subcortical and strategic infarct as subtypes d. hypoperfusion, hemorrhagic and mixed with Alzheimer's Dementia as subtypes e. in DSM - 5, considered as either a major or mild neurocognitive disorder

Rationale: The term Vascular Cognitive Impairment (VCI) is an umbrella term that encompasses all vascular - related cognitive impairment. The etiology of VCI includes hypoperfusion, or hemorrhage. VCI may also result from vascular lesions or infarcts of the cortex, sub cortex or other strategically located areas of the brain. Additionally, VCI may be mixed with Alzheimer's Dementia. VCI is characterized by attentional and executive impairment and may be accompanied by depression. In the DSM - 5, The term Vascular Disease replaces Vascular Dementia. Vascular Disease may present as a Major or a Mild Neurocognitive Disorder. Prion disease is a transmissible neurodegenerative condition best known as Creutzfeldt-Jakob disease (CJD).

The recommended option is b. ______O'Brien JT. Vascular Cognitive Impairment. American Journal of Geriatric Psychiatry. 2006:14; 724 - 33.

Lyketsos CG. Chapter 13. Dementia and Milder Cognitive Syndromes. In: Blazer DG, Steffens DC, eds. The American Psychiatric Publishing Textbook of Geriatric Psychiatry. Fourth edition. Washington, DC: American Psychiatric Publishing, Inc; 2009. pp 243 - 260

American Psychiatric Association. Neurocognitive Disorders. In: American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders DSM - V. Washington, DC: American Psychiatric Press; 2013: 591- 643.

5. Vascular dementia (VaD) and stroke are consequences of cerebrovascular disease. Which one of the following is the most important risk factor for cerebrovascular disease?

a. family history b. hyperlipidemia c. smoking d. hypertension Geriatric Psychiatry Assessment Program Chapter 15 Vascular Dementia 4

e. hypotension

Rationale: The reduction of vascular risk factors in mid life may provide an opportunity to preserve cognitive function in later life. Hypertension and diabetes are both major risk factors for cerebrovascular disease and dementia. Hypertension is a predisposing risk factor for the development of arteriosclerosis, atherosclerosis and ischemic attacks. Other risk factors include arrhythmia, hypoxic events, diabetes mellitus, vasculitis and coagulopathies, pulmonary disease, sleep apnea and hyperlipidemia. Smoking and alcohol are additional risk factors. There is growing interest and debate on the impact of hypotension and in particular, orthostatic hypotension on cognition.

The recommended option is d. ______

Carlsson CM, Gleason CE, Puglielli L and, Asthana S. Chapter 65. Dementia Including Alzheimer's Disease. In: Halter JB, Ouslander JG, Tinetti ME, et. al. Hazzard's Geriatric Medicine and Gerontology.McGraw Hill, New York, 2009. pp 797 - 811

Novak V. Cognition and hemodynamic. Curr Cardiovasc Risk Rep. 2012 October; 6(5): 380–396.

Gorelick PB. Risk Factors for Vascular Dementia and Alzheimer Disease Stroke. 2004; 35: 2620- 2622.

6. Mrs. B is an 85 year old female with a history of hypertension, diabetes mellitus (well controlled with diet), and hyperlipidemia. Her daughter escorts Mrs. B. to your office and states, "She's just not herself." Mrs. B explains, "Well, doctor, I'm an old woman. I'm just slowing down." Mrs. B has no history of stroke or transient ischemia. The family history is positive for dementia in both her father and her older sister. During your neurologic examination you note that cranial nerves are grossly intact. Your cognitive testing reveals deficits in executive function, verbal fluency, and cognitive slowing. MRI of brain reveals enlarged ventricles and evidence of subcortical ischemia. Laboratory studies rule out infection, anemia, electrolyte imbalance and thyroid disease. Which of the following diagnosis is most likely?

a. Vascular cognitive impairment b. Alzheimer's dementia c. Vascular dementia d. None of the above e. A mixed Alzheimer's - vascular dementia (AD/VaD)

Rationale: As vascular dementia and Alzheimer's dementia progress, the cognitive profiles are often similar and differentiation between the two becomes more difficult. It is possible for a patient with prominent vascular risk factors and radiologic evidence of ischemia to have mixed AD/VaD. Prevalence estimates suggest that from 20 to 40-percent of patients with dementia have mixed AD/VaD Geriatric Psychiatry Assessment Program Chapter 15 Vascular Dementia 5

The recommended option is e. ______

Croft S, Cholerton B, Reger M. Chapter 62. Cognitive Changes Associated with Normal and Pathological Aging. In: Halter JB, Ouslander JG, Tinetti ME, et. al. Hazzard's Geriatric Medicine and Gerontology. McGraw Hill, New York, 2009. pp751 - 765.

7. Which one of the following standardized scales is designed to differentiate dementia of the Alzheimer's disease type from vascular dementia (VaD)?

a. Clinical Dementia Rating Scale (CDR) b. Mini-Mental State Examination (MMSE) c. Mini-Cog d. Hachinski Scale e. Montreal Cognitive Assessment

Rationale: The Hachinski Scale measures risk factors for ischemic injury and was designed to discriminate VaD from dementia of the Alzheimer's type. It includes a review of mental status items such as emotional lability, and screens for history of stroke, transient ischemic attacks and symptoms suggestive of cerebrovascular events. The CDR is a clinical scale that indicates the presence of a dementia syndrome and its severity, regardless of etiology. The MMSE is a 30-point cognitive screening test. The Mini-Cog is a brief non-discriminatory dementia screen. The Montreal Cognitive Assessment is a brief screening tool that includes assessment of executive function.

The recommended option is d. ______Borson S, Scanlan JM, Chen P, Ganguli M. The Mini-Cog as Screen for Dementia: Validation in a Population-Based Sample. J Am Geriatr Soc. 2003; 51:1451-1454.

Nasreddine ZS, Phillips NA, Bédirian V, et. al. The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc. 2005 Apr;53(4):695-9.

Podell K, Keller JM. Chapter 5. Neuropsychological Assessment. In: Coffey CE, Cummings JL, eds. The American Psychiatric Publishing Text Book of Geriatric Neuropsychiatry. Third edition. Washington, DC: American Psychiatric Press; 2011: pp 121 - 145.

8. Which one of the following is the most sensitive structural neuroimaging technique for detecting ischemic changes in the brain?

a. Functional magnetic resonance imaging (fMRI) b. Positron emission tomography (PET) Geriatric Psychiatry Assessment Program Chapter 15 Vascular Dementia 6

c. Single positron emission computed tomography (SPECT) d. Computed tomography e. T2-weighted magnetic resonance imaging (MRI)

Rationale: A T2-weighted MRI is the most useful structural imaging technique for visualizing ischemic lesions in white matter and subcortical gray matter. In this type of image, cerebral spinal fluid (CSF) appears white, and while anatomical detail is fair, important pathologies are highlighted, including high-intensity lesions that appear as bright spots. In a T1-weighted MRI scan, CSF appears black, anatomical detail is superior, and the gray-white border is well-demarcated. CT is a good initial neuroimaging test for acute bleed; however, CT is less sensitive than an MRI in detecting ischemic changes. In addition, head CT scanning carries a risk of radiation exposure. PET and SPECT are functional imaging techniques that measure regional cerebral glucose utilization and blood flow, which are not often used clinically even though they demonstrate a characteristic pattern of temporoparietal hypoperfusion in some Alzheimer's disease cases. fMRI measures cerebral perfusion and blood volume, often using the brain oxygen level dependent (BOLD) contrast technique.

The recommended option is e. ______Coffey CE, Kumar A, Ajilore O. Chapter 6. Imaging the Structure of the Aging Human Brain. In: Coffey CE, Cummings JL, eds. The American Psychiatric Publishing Text Book of Geriatric Neuropsychiatry. Third edition. Washington, DC: American Psychiatric Press; 2011: pp 147 - 165.

9. A colleague asks your opinion on a the case of a 61 year old female who presented with mood disturbance and cognitive impairment. The patient has a history of migraine and several ischemic strokes. MRI imaging was remarkable for anterior temporal lobe hyperintensities and subcortical lacunar infarcts. You ask about her family history and your colleague tells you that the patient was adopted, never married and never had children. You recommend that your colleague's next step should be:

a. Order genetic testing b. Schedule positron emission tomography c. Refer for a brain biopsy d. Identify target symptoms and treat e. Request neuropsychologic testing

Rationale: When unclear of the diagnosis, the wise clinician discusses the case with a colleague. MRI findings of hyperintensities in the anterior temporal lobes, subcortical lacunar infarcts, and the clinical history of migraine and ischemic stroke all point to cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL), also known as subcortical ischemic vascular dementia. Geriatric Psychiatry Assessment Program Chapter 15 Vascular Dementia 7

The absence of any family history makes it difficult to recognize that this patient has this inherited disorder caused by mutation of the NOTCH3 gene. CADASIL is characterized by a progressive dementia beginning in the third to sixth decades. The prevalence of psychiatric disorders in CADASIL patients is reported to range from 20% to 41%. The psychiatric disturbances reported with the highest frequency are mood disturbances (9-41%). The psychiatric disturbances have not been well-described. Cognitive impairment has also been reported.

The recommended option is a.

______Valenti R, Poggesi A, Pescini F, et al. Psychiatric disturbances in CADASIL: a brief Review. Acta Neurol Scand. 2008; 5:291-5.

Foster N. Chapter 7. Molecular Imaging in Neuropsychiatry. In: Coffey CE, Cummings JL, eds. The American Psychiatric Publishing Text Book of Geriatric Neuropsychiatry. Third edition. Washington, DC: American Psychiatric Press; 2011: pp177 - 209.

10. Mr. K is a 76 year old gentleman with a history of hypertension and multiple falls. He is sent by the assisted living facility for evaluation and treatment of late onset psychosis with aggressive behavior. You note a history of memory deficits, executive impairment, apathy, and emotional incontinence. When you examine Mr. K, you are immediately aware that he is incontinent. He is dysarthric and difficult to understand. Attempting to assess passive range of motion in his upper extremities you observe significant rigidity. He also has frontal release signs. A nine-month-old MRI reveals hyperintensities on T2 weighted images in the periventricular and deep white matter regions. Which of the following type of dementia best correlates with the clinical and MRI findings?

a. CADASIL b. Mixed Alzheimer's/Vascular dementia c. Subcortical arteriosclerotic encephalopathy d. Alzheimer's dementia e. Vascular dementia

Rationale: Binswanger's disease or, subcortical arteriosclerotic encephalopathy, is gradually progressive dementia caused by hypoxic ischemia of the small penetrating vessels supplying the deep white matter. Neurologically, these patients may present with frontal release signs, weakness, ataxia, rigidity, small -stepped gait, falls, dysarthria and urinary incontinence. Neuropsychiatric findings may include deficits of memory and executive function, diminished attention, impaired judgment, apathy, emotional incontinence and pseudobulbar palsy as well as aggressive behavior. Hyperintensities in the periventricular and deep white matter regions have been reported on MRI T2-images. Geriatric Psychiatry Assessment Program Chapter 15 Vascular Dementia 8

The recommended option is e. ______

Scharre DW. Chapter 28. Neoplastic, Demyelinating, Infectious and Inflammatory Brain Disorders. In: Coffey CE, Cummings JL, eds. The American Psychiatric Publishing Text Book of Geriatric Neuropsychiatry. Third edition. Washington, DC: American Psychiatric Press; 2011: p 670.