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Vascular Cognitive Impairment Often Unrecognized
by Lisa Bianco

The decline in thinking skills due to vascular dementia is caused by conditions that block or reduce blood flow to the brain. Brain cells are deprived of vital oxygen and nutrients. Related dementias like Alzheimer's disease share some common symptoms.

The vascular changes that play a key role in storing and retrieving information can cause memory loss that looks very much like Alzheimer's disease. Virtually anywhere in the body inadequate blood flow can damage and eventually kill cells. One of the body's richest networks of blood vessels is located in the brain, making it especially vulnerable. Sometimes sudden changes in thinking skills occur after strokes that block major brain blood vessels. The spouse of a person with vascular dementia may first notice mild changes and thinking problems in his or her partner. But the gradual worsening of these changes because of repeated multiple minor strokes that affect smaller blood vessels, leads to cumulative damage. Many experts prefer the term "vascular cognitive impairment (VCI)" to "vascular dementia" because it better expresses the concept that vascular thinking changes can range from mild to severe.

Although common, vascular dementia remains underdiagnosed — much like Alzheimer's disease. Depending on the severity of the blood vessel damage and the part of the brain affected symptoms can vary widely. Depending on the specific brain areas where blood flow is reduced memory loss may or may not be a prominent symptom. Vascular dementia symptoms may be most obvious when they happen soon after a major stroke. Changes in thinking and perception may include: confusion, disorientation, trouble speaking or understanding speech and vision loss.

More typical physical stroke symptoms, such as a sudden headache, difficulty walking, or numbness or paralysis on one side of the face or the body can happen at the same time. As the damage accumulates from the multiple small strokes or other conditions that affect blood vessels and nerve fibers deep inside the brain more gradual thinking changes occur. Some early signs of widespread small vessel disease are: impaired planning and judgment; uncontrolled laughing and crying; diminished ability to pay attention; impaired function in social situations; and trouble finding the right words when speaking.

Because vascular cognitive impairment may often go unrecognized, professional screening with brief tests should be done to assess memory, thinking and reasoning for everyone considered to be at high risk for this disorder. Individuals at highest risk include those who have had a stroke or a transient ischemic attack (TIA, also known as a "ministroke"). High-risk groups also include those with high blood pressure, high cholesterol, or other risk factors for heart or blood vessel disease. Professional screening for depression is also recommended because depression commonly coexists with brain vascular disease and can complicate the cognitive symptoms.


The Long Journey to Diagnosis
Vascular dementia struck my own family, slowly showing up in my father's deteriorating abilities to follow directions, obey traffic laws while driving, count money, do math and admit to his growing number of limitations. My mother, Shirley Bianco eventually became my dad's caretaker. She remembers the beginning of changes in my father's behavior starting as early as 2005. But because vascular dementia comes on years before it is actually diagnosed, my dad's official diagnosis would not be confirmed until late 2012.

My mother wasn't able to pinpoint the exact year, but somewhere around 2005 my dad had been making serious mistakes. When he drove he often crossed over the center line and increasingly was unable to drive in a straight line. Once during this period a driver contacted the police by cell phone because the driver saw my father swerving and assumed he was either drunk or on medication. My dad had two knee replacements during this period, and had surgery for spinal stenosis. During one trip to the doctor's office my mother, riding in the back of the car watched my father attempt to drive to the doctor's office he'd been traveling to for years. His brother in the front seat gave him directions but my dad couldn't seem to follow them.

My father had more and more trouble walking and he had begun to develop a shuffling gait. A shuffling gait can be a symptom of dementia. But at the time my mother guessed these could be normal signs of aging. But the final blow to my father's ability to drive happened on a hunting trip with my brother. My dad wasn't able to actually walk well enough to hunt but enjoyed the drive with my brother and the feeling of the woods around him. However, my brother left the keys in the car. My dad decided to drive to their favorite ice cream spot. The only problem was that he drove on the wrong side of the road. Once again the police stopped him for this really dangerous offense. In the end his case came before a judge and my father lost his driver's license. Thinking that the driving issues could mean my father had vision problems, mom had his vision tested and it was fine for a 75 year old man.

Physical therapy didn't help the walking problems either, so the next step was getting my dad tested by a neurologist. Sometime in the next year my mom had an experience with my dad that confirmed a shocking deterioration in his ability to think and do math. My parents frequently ate out and my dad enjoyed paying the bill in cash. He was proud that he earned enough money in his career to be able to eat out. With the final bill coming to $23.00 mom told dad that he would need two twenties to pay the bill. When the waitress arrived back at their table my dad told her to keep the change. He had just given her a $17.00 tip! Shocked, mom said to him, "Do you realize how much of a tip you just gave that waitress?" My dad had always been a modest tipper at best. But this time he had a hard time understanding what was wrong and looked at my mother blankly. When this happened, mom understood for the first time that my father had lost his ability to do the math required to figure out a tip. She knew he most likely had dementia. And like everything else, his problems with math had probably been going on for a long while.

The first neurologist suspected that dad had hydrocephalus, another condition with the symptom of a shuffling gait. My father also had two other symptoms of hydrocephalus — short term memory loss and incontinence. Hydrocephalus is the buildup of too much cerebrospinal fluid in the brain. Treatment usually involves surgery to insert a shunt in the brain — a flexible but sturdy plastic tube that moves the cerebrospinal fluid to another area of the body where it can be absorbed. The first neurologist had inclusive results. At the end of 2012 a second neurologist, Dr. Eric Dade, finally confirmed my mother's suspicions and pronounced the diagnosis of vascular dementia. Dr. Horowitz at Presbyterian Hospital performed the shunt surgery.

Educating the Caretaker
My mother had for years taken on more and more caretaking tasks for my dad. But now with the correct diagnosis in hand she set out to educate herself on exactly what to expect and how to deal with it. Ever ingenious, mom found some excellent resources listed below:

  • 12 week Caregiving course at UPMC
  • Caregiver Support Group my mother initiated forming with people she met in UPMC's Caretaking course.
  • Asbury Heights Assisted Living Facility, 700 Bower Hill Road, Pittsburgh, PA 15234, (412-341-1030) hosted some presentations by the renowned Teepa Snow, a dementia and Alzheimer's care expert originally trained as an occupational therapist. She trains and helps agencies, facilities and families. (Her training videos are also found on YouTube.)
  • Southminster Presbyterian Church, 799 Washington Road, Mt. Lebanon, PA 15228. The church's medical equipment lending service connects people who need medical equipment to make their home more rehab friendly during recovery, or when more permanent medical assistance is needed. This free service has available: Wheelchairs (handles on wheels); Transfer chairs (no handles on wheels); Rollaters (walker with hand brakes and bench); Walkers (with and without wheels); Canes (single and four-prong); Crutches; Potty chairs and frames; Toilet seat risers; Tub chairs; Shower transfer benches. To make an appointment to donate or receive equipment, contact the Church Office at 412-343-8900.
  • The 36-Hour Day: A Family Guide to Caring for People Who Have Alzheimer Disease, Other Dementias, and Memory Loss, by Nancy L. Mace, MA and Peter V. Rabins, MD, MPH (A Johns Hopkins Press Health Book). This book helps family members and caregivers address the host of challenges that come with dementia and keeping the caretaker sane by coping with their own emotions and needs. My mother considered this book her bible on Alzheimer's disease and dementia. Unfortunately it only came into her life a month before my father passed away.

These resources and the help of family members, friends and a Steven Minister from St. Bernard Church were invaluable in helping my mother get through the remaining five years of my father's life, as his dementia worsened and his capabilities decreased. Her hope is that sharing her story and these resources will help others who find themselves in the same situation.

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