Controversies in vascular dementia

Gustavo C. Román
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Abstract

The main controversies in the field of vascular dementia (VaD) include the nosological classification of this disorder, the definition of dementia, the differences between the different sets of diagnostic criteria, the concept of Binswanger disease, the role of vascular lesions in Alzheimer disease, and the results of cholinesterase trials in VaD. Vascular Cognitive Disorder (VCD) is the most current nosological classification for the global diagnostic category of cognitive impairment of vascular origin, ranging from mild cognitive impairment (MCI) to vascular dementia. It includes specific disease entities such as poststroke VaD, CADASIL, Binswanger disease, and AD plus CVD. Vascular cognitive impairment (VCI) is limited to cases of vascular MCI without dementia, by analogy with the concept of amnesic MCI, currently considered the earliest clinically diagnosable stage of Alzheimer disease (AD). The main problem of VaD stems from the currently accepted definition of dementia that requires memory loss as the sine qua non for the diagnosis. This may result in over-sampling of patients with AD worsened by stroke (AD+CVD). We have proposed an operational definition of dementia in VaD based on the presence of abnormal executive control function, severe enough to interfere with social or occupational functioning. This may increase the sensitivity and specificity of the NINDS-AIREIN criteria. In donepezil trials in VaD that excluded prestroke MCI, the placebo groups were different from those in AD without CVD, and in AD+CVD trials.

血管性痴呆的争议
血管性痴呆(VaD)领域的主要争议包括该疾病的分类学分类、痴呆的定义、不同诊断标准之间的差异、Binswanger病的概念、血管病变在阿尔茨海默病中的作用以及胆碱酯酶试验在VaD中的结果。血管性认知障碍(VCD)是血管性认知障碍全球诊断类别中最新的分类学分类,范围从轻度认知障碍(MCI)到血管性痴呆。它包括特定的疾病实体,如卒中后VaD、CADASIL、Binswanger病和AD合并CVD。血管性认知障碍(VCI)仅限于无痴呆的血管性MCI病例,与遗忘性MCI的概念类似,目前被认为是阿尔茨海默病(AD)临床最早可诊断的阶段。VaD的主要问题源于目前公认的痴呆定义,即需要将记忆丧失作为诊断的必要条件。这可能导致卒中加重AD患者(AD+CVD)的过度抽样。我们提出了一种基于执行控制功能异常的VaD痴呆的操作性定义,这种异常严重到足以干扰社会或职业功能。这可能会增加NINDS-AIREIN标准的敏感性和特异性。在多奈哌齐排除卒中前MCI的VaD试验中,安慰剂组与无CVD的AD试验和AD+CVD试验不同。
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