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Vascular cognitive impairment (VCI) is a relatively new term intended to encompass and replace the older concept of vascular dementia (VaD). Put simply, VCI refers to cognitive impairment of any severity arising from cerebrovascular disease of any kind. As a new concept, the precise definition of VCI and its operational implementation are not yet established. Some understanding of the history of the concept is essential in understanding the current state of VCI and future likely developments.

Magnetic resonance imaging (MRI) has opened up the way to diagnose dementia in vivo. It provides clear evidence for hippocampal atrophy in Alzheimer's disease (AD), lobar atrophy in frontotemporal lobar degeneration (FTLD), vascular changes in VaD, and specific findings in some rare forms of dementia. In addition, the traditional role of excluding space-occupying lesions has been kept and the combination of both aspects has rendered MRI indispensable in the diagnostic work-up.

This chapter explores the frequency with which dementing illnesses occur in populations, their distributions by personal characteristics, and what is known about their causes and potential protective factors. The primary focus is on the most common forms of dementia: Alzheimer's disease and vascular dementia. The chapter summarizes clinical and pathologic features of Alzheimer's disease and vascular dementia, and highlights recent theories of how risk factors affect brain reserve. With the evolution of the epidemiology of dementia from case-control studies to prospective cohort studies has come a new set of methodological challenges. These include identification of representative populations, enhancing subject participation and retention in studies, the need to include institutionalized as well as community-dwelling populations, the non-standardized use of cognitive tests to screen for dementia, and the complexities of the diagnostic process itself. Finally, the chapter summarizes risk and protective factors for disease expression, including cardiovascular risk factors, lifestyle factors, and factors that affect brain reserve.

The term ‘vascular disorders’ covers a range of conditions, including cerebrovascular disease (e.g., stroke, vascular dementia) and specific blood vessel problems, such as aneurysm with associated sub-arachnoid haemorrhage or arteriovenous malformation. An apparently discrete event, such as stroke, is often associated with a prior history of transient ischaemic attacks and pre-existing risk factors (e.g., hypertension). Due to the wide range of conditions subsumed under ‘vascular disorders’, there are a number of roles for the clinical neuropsychologist. These range from early screening to identify possible cognitive changes from pre-stroke vascular problems in people apparently functioning ‘normally’ (e.g., SVD: small vessel disease), through an involvement at the acute, diagnostic, stage (for example, in evaluating cognitive functioning early in the course of a vascular dementia), to an extended participation in the rehabilitation process following stroke. This chapter discusses pre-stroke conditions; definition, diagnosis, assessment, and treatment of stroke; vascular dementia, subarachnoid haemorrhage, and vascular surgery.

There are numerous distinct brain pathologies that underlie a clinical diagnosis of dementia. This chapter focuses on the two most common and well-recognized brain pathologies associated with dementia, Alzheimer’s disease and vascular dementia. The authors describe the distinguishing pathological characteristics of Alzheimer’s disease, followed by the pathological hallmarks of vascular dementia including the characteristics of vessel disease and cerebrovascular tissue injuries. The chapter highlights the importance of mixed or co-morbid Alzheimer’s disease and vascular cerebral injury that has been described in multiple clinical pathologic studies, especially in community-based studies. Finally, the authors discuss how data obtained from both clinical and neuropsychological examination of the brain can be integrated.

This chapter begins with a brief description of the clinical concept of dementia. It then outlines the common dementia illnesses: Alzheimer's disease, vascular dementia, dementia with Lewy bodies, and frontotemporal dementia. This is followed by a discussion of the epidemiology of dementia, living with dementia, survival from dementia, and life after dementia.

Alzheimer’s disease (AD) and vascular dementia (VaD) are considered to be the two most common types of dementia with each of these dementia syndromes believed to represent more or less independent entities. While mixed dementia syndromes are acknowledged, the prevailing point of view continues to suggest that AD and VaD represent disorders with different underlying etiology. This chapter will review some of the recent neuropathological and neuropsychological literature suggesting considerable heterogeneity between AD and VaD. It is our contention that the literature reviewed in this chapter supports the notion that neuropsychological syndromes seen in AD/VaD dementia, in addition to their underlying biological substrate, are best understood as existing along a clinical/pathological continuum or spectrum. This heterogeneity should be leveraged to construct a more sophisticated and heuristically meaningful way to classify patients with dementia.

The term vascular cognitive impairment (VCI) was introduced and designed to encompass the broad spectrum of neurocognitive deficits attributable to cerebrovascular disease, including cerebral infarctions and ischemia, that may involve the cerebral cortex, subcortical nuclei, and subcortical white matter, including lacunes (small infarcts that are 3 to 15 mm cerebrospinal fluid–filled cavities in the basal ganglia or white matter) leukoaraiosis (subcortical white matter), and other vascular-related lesions. The resulting impairment can vary, including the signs-symptoms, the clinical course, and disease severity. Whereas there is now agreement that cerebrovascular disease can be a major contributing factor underlying dementia, there is limited agreement about diagnostic criteria and clinical presentations. This chapter seeks to review pertinent literature on VCI as well as to investigate the construct of mild vascular cognitive impairment. This chapter will also briefly review the history of VCI, epidemiological research, neuropsychological signs and symptoms, and recent research regarding biomarkers, as well as public health and treatment issues.

Syndromes of cognitive, emotional, and psychomotor disturbance in the elderly that are of disabling severity are called dementias and are classified as idiopathic, vascular (VD), and secondary dementias. The main groups of idiopathic dementias (primary degenerative or metabolic disturbances) are those of Alzheimer type. Originally Alzheimer's disease (AD) was the name of an early onset dementia with characteristic cortical lesions. However, similar neuropathological findings are made in the brains of patients with senile dementia; therefore, this group was named senile dementia of Alzheimer type (SDAT). The two forms are often brought into one group, Alzheimer-type dementia (AD/SDAT). Vascular dementia is diagnosed when there is an assumed causal relationship between vascular disorders and the appearance of dementia. Multiinfarct dementia (MID) is a subgroup of VD characterized by a temporary relationship between stroke attacks and the appearance of dementia. This chapter aims to review data indicating disturbance of the 5-HT system in patients with AD/SDAT and non-MID VD. Data about changes in the 5-HT metabolism in ageing are also reported.

This chapter presents a comprehensive understanding of dementia as a commonly encountered condition/syndrome in the nursing care of older adults and offers insights into the health challenges faced by people living with dementia. It will provide nurses with the knowledge to be able to assess, manage, and care for people with dementia in an evidence-based and person-centred way. After a comprehensive overview of the causes, risk factors, and impact of dementia, it will outline best practice to deliver care, as well as to prevent or minimize further ill-health. Nursing assessments and priorities are highlighted throughout, and the nursing management of the symptoms and common health problems associated with dementia can be found in Chapters 14 and 17, respectively. In the past, dementia was most often described in terms of mental disability. However, it is now more often described in terms of neurological disability (i.e. changes in the brain). For example, the Mental Health Foundation describes dementia as:…A decline in mental ability which affects memory, thinking, problem-solving, concentration and perception….The NHS Choices website states:…Dementia describes the effects of certain conditions and diseases on a person’s mental ability, personality and behaviour….Dementia is generally classified according to two international classification systems: the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders fourth edition (DSM-IV); and the International Classification of Diseases tenth edition (ICD-10). Dementia can be defined as a syndrome whereby there is gradual death of brain cells, resulting in a loss of brain ability that is severe enough to interfere with normal activities of living for more than 6 months. Problems with brain function should not have been present at birth and it is not associated with a loss or alteration of consciousness. This latter point distinguishes dementia from delirium, which is a state of mental disorientation that can happen if you become medically unwell, also known as an ‘ acute confusional state’ (Royal College of Psychiatrists, 2009). (See Chapter 11). It is vital that nurses hold central what dementia means for people living with it. For example, people will commonly experience changes to their perception, senses, memory, and the range of skills they need to carry out everyday activities.

The Framingham Heart Study (FHS) was established in 1948 and is the longest, ongoing prospective cohort study studying cardiovascular diseases and stroke. Initially, the FHS was primarily focused on cardiovascular diseases; however, over recent decades data from the FHS have found that lifetime exposure to major cardiovascular risk factors such as hypertension, diabetes mellitus, arterial stiffness, and pressure pulsatility adversely impact neuropsychological functioning particularly in older individuals contributing to the onset of dementia including Alzheimer’s disease. Research from the FHS suggest that appropriate management of cardiovascular risk factors as well as healthy lifestyle practices that include regular blood pressure monitoring, not smoking, and eating a choline-rich diet appear to minimize neuropsychological decline as well as dementia onset.

“Actions speak louder than words.” Although clinician’s behavioral evaluations of dementia most often include assessing episodic memory, declarative memories (e.g., naming and calculating), and executive functions (working memory, letter–word fluency), one of the most important functions of the brain is programing actions, including “how” to move and “when” to move. Patients with Alzheimer’s disease, vascular dementia, and other forms of dementia often have impairments in the systems that mediate these how-apraxic and when-intentional behaviors. Although the presence of these apraxic and action-intentional disorders may help with diagnosis and help doctors gain a better understand these patients’ disability, these functions are rarely tested and are often not well understood. The goal of this chapter is to describe the signs of the various types of apraxic disorders (limb-kinetic, ideomotor, conceptual, ideational, and dissociation) and well as action-intentional disorders (akinesia-hypokinesia, impersistence, perseveration, and defective response inhibition), how to test for these disorders, and their pathophysiology.

Few physical signs or investigative tools are available to psychiatrists to aid them in making their diagnosis. An ability to understand the patient’s mental state is therefore of vital importance in categorizing and precisely communicating their mental disorder. The MSE is the psychiatrist’s most used and useful resource. It elicits psychopathology in particular pat–terns, enabling diagnoses to be made. Psychopathology can therefore be defined as the scientific study of abnormal experience, cognition, and behaviour (Sims, 2002) and was first described by Karl Jaspers in the early 1900s. More specifically, descriptive psychopathology is the subjective description of abnormal experience as related by patients and the objective observation of their behaviour. It has facilitated the creation of diagnostic systems, for example ICD-10 and DSM-IV, grouping symptom clusters and classifying which signs and symptoms indicate a particular diagnosis. In this chapter, you will be presented with a number of clinical sce–narios, which will enable you to familiarize yourself with some of the important phenomenological terms used by clinicians to help classify experience and illness. We have attempted to incorporate signs encoun–tered in all elements of the MSE and have used clinical examples from the main diagnostic groups.

Questions

When judging rotational alignment of the radius on an anteroposterior radiograph the radial tuberosity should lie in which orientation in relation to the radial styloid?

Select the single most appropriate answer.

Facing anteriorly

Facing away from the ulna

Facing posteriorly

Facing the ulna...

Questions

Anterior band inferior glenohumeral ligament

Middle glenohumeral ligament

Superior glenohumeral ligament

Subscapularis

Acromioclavicular ligament

Coracoacromio ligament

Corococlavicular ligaments

Superior labrum

Posterior labrum

Posterior band inferior glenohumeral ligament

For each of the following scenarios select the most appropriate option from the list. Each option...