Current Concepts in Vascular Cognitive Impairment and Pharmacotherapeutic Implications

Abstract

Objective: To review evolution of the vascular cognitive impairment (VCI) construct, including diagnosis, pharmacotherapeutic implications, and address challenges that will shape future developments. Data Sources: Literature retrieval was accessed through PubMed, from 1966 to December 2008, using the terms vascular cognitive impairment, vascular dementia, post-stroke dementia, vascular cognitive disorder, mild cognitive impairment, criteria, disease progression, outcomes, treatment, prevention, biomarkers, and neuroimaging. Study Selection and Data Extraction: All articles in published English identified from the data sources were evaluated for inclusion. Regarding pharmacotherapy, prospective double-blind, placebo-controlled studies were included as well as extensions or relevant post hoc analyses. Data Synthesis: In the 1970s, “senile dementia due to hardening of the arteries” was used to describe dementia due to vascular causes. This was a narrow view of what is now known to be a common form of cognitive impairment in older people. Multiple infarct dementia (MID) was first proposed to describe dementia attributable to multiple cerebral infarcts, followed by the vascular dementia (VaD) construct, itself meant to be an improvement over MID. The VaD construct had limitations, not the least of which was that, by the time a patient was diagnosed with VaD, the opportunity for prevention was lost. Thus arose the concept of VCI, representing a group of heterogeneous disorders that share presumed vascular causes. The importance of VCI is centered on the fact that vascular risk factors are treatable, and thus should lead to a reduction in the incidence of cognitive impairment due to vascular causes. There is evidence that treatment of hypertension can lead to a reduction in the incidence of cognitive impairment and dementia, and that treatment of VaD with acetylcholinesterase inhibitors may be beneficial. Conclusions: Careful attention needs to be given to controlling vascular risk factors in at-risk patients. Pharmacists should play an active role in this important area of geriatric pharmacotherapy.