Stages of Vascular Dementia

Vascular dementia is the second most common type of dementia after Alzheimer's disease. It is caused by reduced blood flow to the brain, which damages and eventually kills brain cells. Other common dementias, such as Alzheimer's, frontotemporal dementia and dementia with Lewy bodies, are caused by abnormal proteins building up in the brain.

Like other dementias, vascular dementia is progressive and is usually described in three stages: early, middle and late. But it often progresses differently from Alzheimer's, and the stages are only a rough guide.

Types of vascular dementia

The type depends on what is damaging the blood supply, and it affects how symptoms start and progress.

• Subcortical vascular dementia. Thought to be the most common type. It is caused by disease of the tiny blood vessels deep in the brain (small vessel disease) and develops slowly and gradually.
• Stroke-related (post-stroke) dementia. Develops after a major stroke. Many people have problems with thinking in the weeks and months after a stroke, and some improve, but about one in five go on to develop vascular dementia within six months.
• Multi-infarct dementia. Caused by a series of small strokes, some of which may go unnoticed. The damage builds up until it affects memory and thinking.
• Mixed dementia. At least one in ten people with dementia have more than one cause. The most common combination is Alzheimer's disease with vascular disease.

How vascular dementia progresses

Many people have periods where their symptoms stay stable, followed by a sudden drop in their abilities, often after another stroke or mini-stroke. This is known as "step-wise" progression. When vascular dementia is caused by small vessel disease, it tends to get worse more gradually, more like Alzheimer's disease.

It's hard to predict when the next change will come. A sudden change over a day or two can also be a sign of something else, such as an infection causing delirium, or a new stroke. New stroke symptoms, such as weakness on one side of the body or slurred speech, need urgent medical attention: call 999.

Early stage

The early stage can last for months or years, and the person can usually live fairly independently. Memory loss is often not the main early symptom, unlike in Alzheimer's. The most common early symptoms are:

• problems with planning, organising, making decisions or solving problems
• difficulty following a series of steps, such as cooking a meal
• slower thinking
• problems concentrating, including short periods of sudden confusion
• mild memory problems, such as forgetting names or recent events
• less fluent speech
• mood changes, especially depression, anxiety or apathy, which are particularly common in vascular dementia

In subcortical vascular dementia, early symptoms can also include loss of bladder control, unsteadiness and falls, weakness on one side, clumsiness and reduced facial expression. After a stroke, there may be physical effects such as a weak limb, speech problems or trouble swallowing.

Because brief memory tests used in GP surgeries focus on memory and orientation, a person in the early stage of vascular dementia may score well, which can delay diagnosis.

Middle stage

Symptoms become more noticeable and the person needs increasing support with everyday life. There may be:

• more marked changes in mood, personality and behaviour, including agitation or rapid mood swings ("labile mood")
• more problems with memory
• increasing difficulty communicating
• more confusion, including sundowning (feeling confused or unsettled in the late afternoon and evening)
• needing reminders and some help with washing and dressing
• sometimes delusions, such as believing someone has stolen from them. Hallucinations are less common

See what happens in the middle stage of dementia for more on supporting someone at this point.

Late stage

In the late stage, almost every part of daily life is affected, and the person needs a high level of care. Common symptoms include:

• severe difficulty with speech and understanding, possibly losing the ability to speak
• disorientation in time and place
• not recognising familiar people and places
• distressed behaviour
• mobility problems and falls
• difficulty eating, drinking and swallowing
• loss of bladder and bowel control

Read more about end stage dementia and caring for someone in the final months.

Life expectancy

On average, people live around five years after a vascular dementia diagnosis, less than with Alzheimer's disease. This is mainly because people with vascular dementia are more likely to die from a stroke or heart attack than from the dementia itself. Averages hide a wide range, though. See dementia life expectancy for figures for every type.

Diagnosis

Diagnosis usually involves a medical history, a physical examination, blood tests to rule out other causes, tests of memory and thinking, and a brain scan (usually MRI) to look for strokes or damage to small blood vessels. A key part of the diagnosis is linking the thinking problems to signs of vascular damage on the scan.

Treatment

There is no cure for vascular dementia, and damage that has already happened can't be reversed. Treatment aims to tackle the underlying causes to reduce further damage, which may help slow it down:

• treating high blood pressure, high cholesterol and diabetes
• medicines such as aspirin, clopidogrel or anticoagulants to reduce the risk of clots and further strokes, where appropriate
• stopping smoking, keeping active, eating a healthy balanced diet, losing weight if needed, and cutting down on alcohol

Alzheimer's medicines (donepezil, galantamine, rivastigmine and memantine) aren't used for vascular dementia on its own, because they haven't been shown to help. They may be offered to people with mixed dementia, for example vascular dementia with Alzheimer's disease.

Non-drug support also matters: cognitive stimulation therapy in the early to middle stages, occupational therapy, physiotherapy, speech and language therapy, and treatment for depression.

Vascular dementia compared with other types

See also stages of Alzheimer's disease, stages of Lewy body dementia and the 7 stages of frontotemporal dementia.