On 7/12/19, Dr. Nothem presented a case of elderly gentleman complaining of urinary incontinence of 3-4 weeks duration. On interviewing, was noted to have incongruent speech, forgetfulness and word finding difficulty. PMH was significant for HTN, HLD, PVD, DMII, BPH, adjustment disorder with depressed mood, anxiety, depression and childhood ADHD with hyperactivity. Pertinent medications included gabapentin, memantine and quetiapine. Patient also has history of ETOH dependence in remission, is a current smoker (ppd unclear), and lives alone with two dogs.
First, lets review types of urinary incontinences and what conditions can cause it.
On physical exam, patient was tachycardic to 100s and hypertensive to 190s/100s. On exam, was noted to have pressured speech, abnormal affect, disorganized thought pattern, frequent word finding difficulty, impaired repetition and trouble naming objects. Gait was normal.
DDx incuded acute stroke, NPH, toxic metabolic encephalopathy, Korsakoff syndrome, severe depression, vs dementia (Alzheimer’s, vascular).
Labs were unremarkable along with negative UDS. CTOH showed diffuse ventricular dilatation disproportionate to the degree of dilatation of the cerebral sulci most likely due to diffuse mild to moderate cerebral atrophy. Old infarct in left caudate head/anterior limb internal capsule. MRI with no acute cerebral infarction, multifocal old bilateral lacunar infarcts, multifocal and confluent hyperintense lesions in the periventricular and subcortical white matter without contrast enhancement, restricted diffusion or mass effect, diffuse moderate cerebral atrophy.
Neurology, Psychiatry and Geriatric teams were consulted. Based on workup, patient was diagnosed with mixed dementia (vascular, alcohol related brain damage vs korsakoff, dementia Alzheimer’s type).
Main topic key points: Vascular Cognitive Impairment (VCI)
- VCI is a large group of disorders with cognitive impairment that is caused by or associated with vascular factors. It encompasses dementia and milder forms of cognitive impairment caused by chronic vascular disease.
- Patients often have systemic vascular risk factors and stroke history
- Patients present with abrupt changes (step-wise decline) in cognition and cognitive slowing disproportionate to memory impairment
- Two warning signs: Early gait impairment and emotional incontinence (inability to control their emotions)
- On MRI brain imaging, findings include diffuse white matter changes, cerebral microhemorrhages and/or cortical infarcts beyond expected for age, severe intracranial disease
- Treatment includes acetylcholinesterase inhibitors (Donepezil, rivastigmine, galantamine), NMDA receptor antagonist, memantine
- Treatment and management of vascular risk factors – antiplatelet agents, smoking and alcohol cessation, diabetes control, BP control, exercise
- Treatment and management of neuropsychiatric symptoms – Olanzapine, risperidone and quetiapine
- Use caution with anti-hypertensives with concern for perfusion compromise. No clear targets determined yet for VCI.
- Survival estimated to be ~5 years for both VCI and vascular dementia
- Palliative care often recommended to decreased burden for caregivers and provide informed treatment decisions for this incurable disease
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