(Stroke. 1997;28:459-463.)
© 1997 American Heart Association, Inc.
Articles |
Status of Risk Factors for Dementia Associated With Stroke
the Center for Stroke Research, Department of Neurologic Sciences, Rush Medical Center, Chicago, Ill.
Correspondence to Philip B. Gorelick, MD, MPH, Center for Stroke Research, Department of Neurologic Sciences, Rush Medical Center, 1645 W Jackson, Suite 400, Chicago, IL 60612.
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Abstract |
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 Top Abstract IntroductionTerminologyPutative Risk FactorsStatus of Risk Factors...Where Should We Be...References |
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Background Cognitive impairment associated with vascular disease may be the only preventable form of dementia of late life. Identification of risk factors for dementia associated with stroke may be a prelude to improved intervention.
Summary of Review I reviewed putative risk factors for dementia associated with stroke. These included demographic, atherogenic, stroke-related, and genetic factors. Key studies from the English literature were reviewed and graded according to quality of evidence ratings (classes I, II, and III). Although many of the cardiovascular disease risk factors are logical antecedents of dementia associated with stroke, age was the only factor that could be considered a well-documented risk factor.
Conclusions We should continue to support efforts directed at primary stroke prevention and the brain-at-risk and predementia stages. Additional rigorous epidemiological study is needed to clarify risk factors for dementia associated with stroke.
Key Words: dementia • risk factors • stroke prevention
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Introduction |
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In some regions of the world where stroke is common, vascular dementia (VaD) frequency rates may be higher than those of Alzheimer's disease (AD).1 2 3 Vascular and degenerative dementias together are estimated to affect more than 1 in 30 Americans and cost over $90 billion annually.4 While research advances are providing a clearer understanding of prevention and treatment of AD, at present VaD may be the only preventable form of dementia of late life.5 6 7 In this review I discuss the status of risk factors for dementia associated with stroke as a prelude to improved intervention.8 9 10
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Terminology |
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VaD, a term that has a broader connotation than "multi-infarct" dementia,11 refers to any dementia resulting from cerebral blood vessel disease.12 It is used most commonly to describe dementias caused by thromboembolic cerebrovascular disease but is not restricted solely to this type of stroke. Our thinking about VaD has shifted from broad categorization to identification of specific vascular mechanisms that contribute to cognitive impairment.5 9 13 The most recent research diagnostic criteria for VaD14 15 incorporate neuroimaging technology, comprehensive neuropsychological parameters, and brain necropsy findings to help elucidate vascular mechanisms that may cause cognitive impairment. These criteria,14 15 however, have been criticized for being overinclusive and overlapping and have not been validated.
VaD may have a wider range of effect than recognized previously. Since both stroke and dementia increase exponentially with age, there may be significant overlap between vascular and degenerative dementia. This remains to be proved, however, since there is a paucity of clinical and neuropathological studies that characterize VaD16 and "mixed" dementia. Some have argued that there is no such entity as VaD but only different vascular causes of cognitive impairment. For this reason I have chosen the term "dementia associated with stroke." This term provides a more accurate description of our present knowledge of VaD. In this review, the operational criteria for "dementia associated with stroke" are broad, since criteria for VaD have not been validated, and refer to the major research criteria for defining VaD.14 15 Consequently, risk factors will have tighter or looser associations depending on how restrictive or broad the criteria are. Study of patients with clinically diagnosed AD and high risk of stroke may clarify the situation, since there may be a vascular component to the dementia in these patients.17
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Putative Risk Factors |
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It is assumed that risk factors for VaD are the same as those for stroke.18 While this assumption is logical, only recently has there been systematic study to elucidate such factors. There has not been a general consensus, however, about risk factors for VaD. This may be explained by study of different populations with the use of disparate methods.13 For this reason I refer to these factors as "putative" or tentative. With refinement of study methods, consistency regarding risk factors for VaD will likely emerge. I now explore potential demographic, atherogenic, genetic, and stroke-related risk factors.
Demographic Factors
As with other dementing illness of later life,19 20 21 the frequency rates of VaD generally rise exponentially with age.22 These findings are consistent across studies23 24 and suggest that age is a substantial risk factor for dementia associated with stroke.
Certain race/ethnic groups may be at higher risk of VaD. This has been shown for Orientals1 2 and may also be the case for others that are at high risk of stroke such as blacks.17 Such groups may suffer a double burden of dementia: a uniformly high rate for AD and additionally a high rate of VaD.25 How race/ethnic group interacts with age remains to be clarified.3 24
Men are thought to be at higher risk of VaD than women.10 This sex distribution is the reverse of AD, in which case women are believed to be at higher risk.
Recently, education has been studied in relation to dementia risk,26 27 28 29 and relatively higher educational attainment is viewed as a protective factor.30 31 Animal studies have shown that complex environmental stimuli promote dendritic growth and brain weight.32 Education also provides skills and strategies for problem solving.26 30 31 Although few in number, VaD studies suggest that lower educational attainment is related to dementia associated with stroke.23 24 It remains to be clarified whether the educational effect in dementia is a direct or indirect one26 33 and whether occupation or income may be better predictors of dementia than education.34
Risk factors for dementia associated with stroke are listed in the Table
. Based on epidemiological evidence from key studies in the English literature, I provide an estimate of the evidence for association according to quality of evidence ratings (classes I, II, and III) and suggested strength of recommendations ratings (types A through E). The operational definitions for these ratings are included in the Table.
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Atherogenic Factors
The frequency of cardiovascular disease risk factors is expected to be high in VaD.35 Stroke leads to VaD, and risk factors for stroke are well defined.6 7 Several controlled studies have recently clarified the role of atherogenic factors in VaD (Table
).
Several atherogenic risk factors or disorders have been associated with cognitive impairment in patients with or at high risk for cerebral infarction. These include hypertension,2 36 cigarette smoking,23 myocardial infarction,23 diabetes mellitus,37 38 and hypercholesterolemia.38 Interestingly, while hypertension in midlife is considered a possible predictor for cognitive impairment in later life,39 once there is dementia associated with stroke, relatively higher systolic blood pressure level may exert a protective effect.23 40 41
The role of other host factors remains to be clarified. These include various cardiac factors, blood lipid subtypes and associated factors, fibrinogen, obesity, anticardiolipin antibodies, and other autoantibodies, to mention a few.42 43 44
Genetic Factors
The role of genetic factors has not been well defined for VaD. This is not surprising because the role of genetic factors in stroke has not been studied thoroughly.7 Autosomal dominant hereditary cerebral hemorrhage with amyloidosis–Dutch type is uncommon,45 as are familial vascular encephalopathies such as "hereditary multi-infarct dementia" and cerebral autosomal dominant arteriopathy with subcortical infarct and leukoencephalopathy (CADASIL).46 47 48 In addition, there is a paucity of information on the role of apolipoprotein E polymorphism in VaD.49 50
Stroke-Related Factors
These factors refer to number, location and volume of stroke, existent atrophy, and the presence of periventricular white matter disease. Cranial CT and MRI of the head play an important role in defining stroke-related factors and predictors of VaD.51 52
Since the systematic clinicopathologic study by Tomlinson and colleagues53 that showed a relationship between dementia occurrence and volume or strategic location of infarction, a host of cranial CT, MRI, and other studies have been published. These studies provide evidence that dementia related to stroke is associated with higher mean tissue loss,54 infarct number,36 37 54 55 location (eg, dominant thalamus and angular gyrus, bilateral infarcts, deep frontal infarcts, left hemisphere infarcts),37 53 56 57 58 59 and degree of "cerebral atrophy" as demonstated by ventricular size, area of subarachnoid space,54 55 and size of the third ventricle.60 61
Periventricular White Matter Lesions
Recognition of the importance of white matter disease in VaD has stemmed from the study of Binswanger's disease.62 63 Both Binswanger's and the role of periventricular white matter lesions in dementia, however, have aroused controversy. Recent studies describe leukoaraiosis (rarefaction or thinning of the white matter), which appears as patchy zones of lucency in the periventricular areas on cranial CT or as decreased signal on the T1 phase of MRI.64 65 66 The spectrum of subcortical white matter change has been defined pathologically.52 67 68 Clinical studies have shown that the presence of periventricular white matter lesions does not always correlate with dementia. Additional studies are needed to define "malignant" and more "benign" forms or stages of periventricular white matter lesions and their pathophysiology and risk factors.69 70 Recently, the Cardiovascular Health Study has shown that more severe white matter disease diagnosed by MRI is associated with impaired cognition and lower extremity function.71 Such a carefully performed community-based study of elders adds substantial descriptive information about "malignant" forms of periventricular white matter lesions.
Silent Cerebral Infarcts
Silent cerebral infarcts, those asymptomatic, unrecognized, or forgotten strokes72 diagnosed by cranial CT or MRI, may prove to have predictive value for cognitive impairment.73 Silent cerebral infarcts that are strategically placed in areas such as the thalamus and deep frontal lobe may prove to be important in the pathogenesis of dementia associated with stroke. At present, there is a paucity of prospective study on silent cerebral infarcts.74
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Status of Risk Factors for Dementia Associated With Stroke: Where Are We? |
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TopAbstractIntroductionTerminologyPutative Risk FactorsStatus of Risk Factors...Where Should We Be...References |
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As the Table
suggests, our knowledge about risk factors for dementia associated with stroke is in an early stage. Although we have gained ground, we have much farther to travel. In fact, beyond age, at present there is not enough epidemiological evidence to consider other factors as well-documented risk factors for dementia associated with stroke. Although many of these are logical antecedents of VaD and common sense dictates that they should be risk factors, additional rigorous epidemiological study is needed to clarify these and other factors. In this regard, VaD has been neglected. Possibly, we have focused our efforts on other aspects of stroke prevention and treatment and have accepted as fact intuitively appealing and logical hypotheses about VaD without confirmatory evidence from rigorous study. VaD remains a field in need of substantial exploration. |
Where Should We Be Headed? |
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TopAbstractIntroductionTerminologyPutative Risk FactorsStatus of Risk Factors...Where Should We Be...References |
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At present, we should continue to support efforts directed at primary stroke prevention7 and the brain-at-risk and predementia stages.75 Because stroke leads to dementia, the prevention of stroke could substantially reduce cognitive impairment in the elderly.13 For those who already have cognitive impairment associated with stroke, we should continue to explore ways to alleviate it and to delay its progression.40 76 77 78 79 80
Key to our understanding of VaD is systematic clinicopathologic study.68 Valid clinical and neuropathological criteria need to be established.14 15 There are certainly "pure" cases of VaD. In the elderly, however, the diagnosis may be confounded by AD changes. This has led many to believe that the vascular component of dementia in the elderly usually occurs within the context of AD and manifests as "mixed" VaD and AD. Furthermore, some have even doubted the existence of VaD in the elderly and attribute most dementia in this age group to AD. Novel neuroimaging strategies51 52 coupled with careful clinicopathologic examination68 may provide the answers needed to determine whether VaD is really mixed dementia or AD alone.16 By exploring these basic issues and maintaining healthy skepticism about intuitively appealing hypotheses that have not been adequately tested, we can then define risk factors for dementia associated with stroke and VaD.
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Acknowledgments |
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This study was supported in part by National Institutes of Health (NIH)/National Institute on Aging (NIA) grant number R01AG10102-06 and NIH/National Institute of Neurological Disorders and Stroke (NINDS) grant number R01NS33430-02. This article is dedicated in memory of Dr Thomas K. Tatemichi, whose untimely death halted the many important future contributions he would have added to an already brilliant career in the field of VaD.
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Footnotes |
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The opinions expressed in this editorial are not necessarily those of the editors or of the American Heart Association.
Received September 17, 1996; revision received November 4, 1996; accepted November 4, 1996.
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 P. B. Gorelick William M. Feinberg Lecture: Cognitive Vitality and the Role of Stroke and Cardiovascular Disease Risk Factors Stroke, April 1, 2005; 36(4): 875 - 879. [Abstract] [Full Text] [PDF]
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P. B. Gorelick Risk Factors for Vascular Dementia and Alzheimer Disease Stroke, November 1, 2004; 35(11_suppl_1): 2620 - 2622. [Abstract] [Full Text] [PDF]
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W. K. Tang, S. S.M. Chan, H. F.K. Chiu, G. S. Ungvari, K. S. Wong, T. C.Y. Kwok, V. Mok, K.T. Wong, P. S. Richards, and A.T. Ahuja Frequency and Determinants of Poststroke Dementia in Chinese Stroke, April 1, 2004; 35(4): 930 - 935. [Abstract] [Full Text] [PDF]
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 D. L. Nyenhuis, P. B. Gorelick, S. Freels, and D. C. Garron Cognitive and functional decline in African Americans with VaD, AD, and stroke without dementia Neurology, January 8, 2002; 58(1): 56 - 61. [Abstract] [Full Text] [PDF]
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 J. A. Luchsinger, M.-X. Tang, Y. Stern, S. Shea, and R. Mayeux Diabetes Mellitus and Risk of Alzheimer's Disease and Dementia with Stroke in a Multiethnic Cohort Am. J. Epidemiol., October 1, 2001; 154(7): 635 - 641. [Abstract] [Full Text] [PDF]
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D. Laurin, R. Verreault, J. Lindsay, K. MacPherson, and K. Rockwood Physical Activity and Risk of Cognitive Impairment and Dementia in Elderly Persons Arch Neurol, March 1, 2001; 58(3): 498 - 504. [Abstract] [Full Text] [PDF]
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 C. D. McCullagh, D. Craig, S. P. McIlroy, and A. P. Passmore Risk factors for dementia Adv. Psychiatr. Treat., January 1, 2001; 7(1): 24 - 31. [Full Text]
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R. Hebert, J. Lindsay, R. Verreault, K. Rockwood, G. Hill, and M.-F. Dubois Vascular Dementia : Incidence and Risk Factors in the Canadian Study of Health and Aging Stroke, July 1, 2000; 31(7): 1487 - 1493. [Abstract] [Full Text] [PDF]
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P. A. Wolf, G. P. Clagett, J. D. Easton, L. B. Goldstein, P. B. Gorelick, M. Kelly-Hayes, R. L. Sacco, and J. P. Whisnant Preventing Ischemic Stroke in Patients With Prior Stroke and Transient Ischemic Attack : A Statement for Healthcare Professionals From the Stroke Council of the American Heart Association Stroke, September 1, 1999; 30(9): 1991 - 1994. [Full Text] [PDF]
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Z. Guo, L. Fratiglioni, L. Zhu, J. Fastbom, B. Winblad, and M. Viitanen Occurrence and Progression of Dementia in a Community Population Aged 75 Years and Older: Relationship of Antihypertensive Medication Use Arch Neurol, August 1, 1999; 56(8): 991 - 996. [Abstract] [Full Text] [PDF]
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L. T. Kwan, B. R. Reed, J. L. Eberling, N. Schuff, J. Tanabe, D. Norman, M. W. Weiner, and W. J. Jagust Effects of Subcortical Cerebral Infarction on Cortical Glucose Metabolism and Cognitive Function Arch Neurol, July 1, 1999; 56(7): 809 - 814. [Abstract] [Full Text] [PDF]
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P. B. Gorelick Cerebrovascular Disease in African Americans Stroke, December 1, 1998; 29(12): 2656 - 2664. [Full Text] [PDF]
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J. Chapman, N. Wang, T. A. Treves, A. D. Korczyn, and N. M. Bornstein ACE, MTHFR, Factor V Leiden, and APOE Polymorphisms in Patients With Vascular and Alzheimer's Dementia Stroke, July 1, 1998; 29(7): 1401 - 1404. [Abstract] [Full Text] [PDF]
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