Vascular Cognitive Impairment: Preventable Dementia

Forget about the end of the Cold War and the emergence of the United States as the world’s unchallenged superpower. Over the last 40 years psychiatrists and neurologists have witnessed an even more successful bid for world domination in dementia diagnosis by Alzheimer’s disease. Initially relegated to the status of a rare presenile dementia, Alzheimer’s is now the diagnosis that we make in the vast majority of our patients with dementia. Indeed, the accepted cardinal clinical features of dementia in major diagnostic systems (early prominent memory loss, progressive course, irreversibility, and interference with normal daily activities) are in reality the features of Alzheimer’s disease. So, it is not surprising that most physicians who look after people with dementia only rarely make the alternative diagnosis of vascular dementia, and, when they do, it is generally in someone who has had a stroke with a solid temporal association with onset of cognitive impairment. Indeed, the Alzheimerization of dementia diagnosis has become so dominant that I must admit I almost invariably label even such patients as “mixed.” Have I got it all wrong? Has the rise of Alzheimer’s disease gone so far that we are effectively missing cases where attention to the control of vascular risk factors might be more helpful than prescription of a cholinesterase inhibitor?

The editors of this book and its contributors are to be thanked and congratulated for lighting a beacon that shines brightly into the murky corners of conceptual and diagnostic knowledge and understanding of vascular cognitive impairment. All the big hitters in the field have contributed to what really is the best available single text on the subject. Genetics, pathology, phenomenology, epidemiology, economics, treatment, and prevention are all covered in authoritative and bang up-to-date detail. But the first and last chapters, both written by the editors, should be compulsory reading for all of us. It was only after I had read the first chapter—a critical appraisal of current diagnostic criteria for vascular dementia—that I truly began to understand just how limited these are and how stacked they are against making a diagnosis of anything other than Alzheimer’s disease. This of course might not matter were it not for the evidence reviewed by contributors to the book that vascular dementia is a real and prevalent diagnosis and can be modified by treatment. In the final chapter, the editors outline a diagnostic framework from which they hope definite operational criteria for what they call vascular cognitive impairment will be developed. Emphasis on subcortical and frontal deficits rather than memory impairment and a challenge to the traditional requirements for remorseless progression, focal signs, and imaging evidence of infarction make up the meat of their persuasive argument. This is one of those rare books that I would have gone out and bought if I hadn’t received my reviewer’s free copy. There is no stronger recommendation.