Category: Neuropsychology

Vascular Dementia

Vascular dementia is a progressive loss of cognitive skills over time, secondary to a blockage or rupture of a blood vessel in the brain.  This term used to be called “multi-infarct dementia”, and other classification systems refer to it as an “arteriosclerotic dementia.”  The primary form is atherosclerosis, in which the plaques of fatty deposits form in the innermost layer of the cerebral artery.  It is almost exclusively a problem of the older adult.  Very young children are prone to arteriovenous malformations, which are congenital defects of the cerebral vascular system.  Most of these AVM’s are located in the brain stem, and do not result in the sort of symptoms observed in the older adult.

The primary deficit of multiple strokes is an impairment of memory.  The impairment may be the ability to recall old information or learn new information.  It is rare that someone forgets old information, yet learns new information at an average level.  The most common scenario is a decreased ability to retain new information, with increasing impairment of long-term personal information that declines with every subsequent stroke.  The specific deficit regarding loss of old personal information is called “episodic memory”, and it may be affected in isolation of other memory impairments.  A specific deficit of this type of memory is exceedingly rare, such that an impairment of new learning is much more common.

Vascular dementia is not limited to memory impairment alone.  The diagnostic criteria stipulates that a patient must have a memory impairment, as well as one other cognitive deficit, in order to be appropriately diagnosed with “Vascular Dementia”.  The most common cognitive impairment from stroke is difficulty with motor control; not just unilateral paralysis, but an impaired ability to carry out motor routines, despite a functional motor system.  Many stroke victims have difficultly recognizing and utilizing objects, despite having an intact sensory system.  Lastly, many stroke suffers have difficulty switching between mental tasks, making plans, and organizing the steps necessary to accomplish a plan.

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Psychological problems are common after suffering one or more strokes.  It is not common to have delusions of persecution or grandiosity after a stroke.  Some forms of progressive dementia affecting the right prefrontal-temporal area exhibit delusions as an early symptom of the disease.  Neglect of the right or left visual space should not be mistaken for a delusion.  It is frequently the case that the patient suffered with a Delusional Disorder prior to the onset of the stroke.  The most common psychological symptom of “Vascular Dementia” is depression.  The depression may arise from difficulty with psychological adjustment to their declined condition, or a general psychomotor retardation without any awareness as to their own psychological condition.  This takes the form of a significantly reduced reaction time, both simple and complex.  The person appears chronically fatigued, laconic, and wanting to be left alone.  This type of depression is often deemed to be “organic” in nature.

The neuropsychological treatment of “Vascular Dementia” is to first determine the exact nature of the deficits through testing.  If the patient is experiencing psychological symptoms of depression or delusions, the clinician must determine if the patient is aware of their abnormal state.  For example, psychotherapy is appropriate for an adjustment problem in a self-aware person, but inappropriate for a severely depressed person with no awareness of their symptoms.  Neuropsychologists use the patient’s remaining cognitive strengths to compensate for their deficits.  Please leave comments regarding this article in the space provided below.

Memory Disorders

Memory Disorders, like “learning disabilities”, is not a term you will find in the “Diagnostic & Statistical Manual of Mental Disorders.”  Neither term is found in either edition.  This is the guide used by many American insurance companies for procedure codes and diagnostic criteria.  “Memory Disorder” is an oft used term by professionals and laypeople alike.  It is likely most people are trying to describe difficulty recalling verbal or visual information, in the absence of another cognitive impairment.  The DSM system refers to memory disorders as an “Amnestic Disorder.”

It is good to rule out a medical factor affecting a person’s ability to think; that is their cognition.  The official diagnostic nomenclature is an “Amnestic Syndrome (due to a general medical condition)”.  The first thing to realize is that a memory impairment caused by a medical condition is generally of rapid onset and dramatic.  Trauma to the central nervous system is the most common cause.  Viral and bacterial infections of the brain may cause mild to profound memory impairments as well.  The damaging factor does not have to originate in the central nervous system.  Low oxygen saturation in the blood and bodily dehydration are common causes of a memory impairment secondary to a medical condition.  Specific vitamin deficiencies may cause memory impairment, as well as unwanted reactions to many medications.  Most of these medical conditions also reduce attention, vigilance, and orientation to one’s environment.  Perhaps the most difficult to detect are sub-clinical vitamin deficiencies and dehydration that test within the average range, but produce a measurable decline in cognitive performance.

What should we expect from our memories in the first place?  By the age of 50, we all begin to have a reduced ability to find names for things, and difficulty recalling verbal information without some prompt or context.  Many people call this the CRS Syndrome; alternately entitled “can’t remember sh–.”  The differential diagnosis is the recognition memory of the person.  Utilizing memory tests with a recognition component reduces the gulf between chronological ages.  It is also necessary to utilize tests that have been normalized on different age groups.  These tests attempt to make a level playing field between different ages.  The differential diagnosis between normal aging and a dementia should be performed by a trained professional.

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If you believe you have a memory impairment, consider consulting a neuropsychologist.  They will administer tests normed for your specific age, and often education as well.  Do not consider yourself diagnosed based upon a test in a magazine or on the internet.  Memory is built upon other cognitive skills, such that verbal or visual memory should not be assessed in isolation.

Many people confuse poor immediate attention as a memory impairment.  It is likely at the root of many medical causes of an “Amnestic Disorder.”  The ability to sustain one’s attention over time is called “vigilance”.  If a person has poor immediate attention, they will have difficulty encoding new verbal and visual information.  If, after a delay, the person can recall the same small amount of information, then attention is likely a greater factor then memory.  It is also difficult for the attention impaired to chunk (organize) information for greater recall.

The initial step in the diagnosis of a “memory disorder” is to administer tests to determine if the disorder exists.  If the disorder exists, then consider ruling out medical factors causing the poor visual and/or verbal memory functioning.  If no medical factors can be determined, then the next step is remediation.  Immediate attention is the most proven remediable skill.  The remaining treatments are largely compensatory strategies to build on the patient’s cognitive strengths.  Please leave comments regarding this post on “memory disorders” in the space provided below.