Vascular dementia

Introduction to vascular dementia Vascular dementia (VaD or VD) refers to severe cognitive dysfunction syndrome caused by ischemic stroke, hemorrhagic stroke, and cerebrovascular disease that causes hypoperfusion in the brain, such as memory, cognition, and behavior. The prevalence of VD in China is 1.1% to 3.0%, and the annual incidence rate is 5-9/1000. Vascular dementia is one of the common causes of senile dementia. basic knowledge The proportion of illness: 0.001% Susceptible people: the elderly Mode of infection: non-infectious Complications: depression, urinary tract infection, acne

Causes of vascular dementia

Cerebral hypoxia (20%)

An important part of the cerebral cortex involved in cognitive function and a small blood vessel lesion caused by hypertension and small arteriosclerosis, which is sensitive to ischemia and hypoxia, has long been in an ischemic hypoperfusion state, making the nerve in this part Delayed necrosis occurs and cognitive dysfunction gradually develops. Patients with clinically common vascular dementia may have near memory loss, mood or personality changes after repeated transient ischemic attacks. Foreign scholars have found that cognitive dysfunction in patients with cardiovascular disease, the number of patients with a history of heart failure or arrhythmia, the incidence of dementia is significantly higher than the same age group of controls.

Hemorrhagic lesions (20%)

Including subdural hematoma and subarachnoid hemorrhage, and hemorrhagic hematoma in the cerebral hemisphere, direct destruction and indirect compression of the brain parenchyma, and block the cerebrospinal fluid circulation pathway, clinical manifestations of varying degrees of dementia.

Infection factor (20%)

Including non-specific vasculitis, as well as tuberculosis, syphilis, fungi, parasites, etc. can be the cause of cerebrovascular dementia. In addition, blood diseases, carbon monoxide poisoning, and central nervous system de-sheathing diseases can occasionally cause cerebral ischemia or cerebral infarction, and then symptoms of dementia. Wallin et al. have proposed a non-multiple infarction cerebral blood dementia with neurotransmitter defects, which is worth noting.

Family history (15%)

Family members of patients with partial vascular dementia (larger family members, not limited to immediate relatives such as grandparents) have morbidity.

Other factors (10%)

Old age, smoking, history of recurrent stroke, and low blood pressure are prone to vascular dementia.

Pathogenesis:

Cerebrovascular disease is the basis of VaD, and hemorrhagic or ischemic damage can be seen in the brain parenchyma. Ischemic is more common. Large areas of infarction in the brain and certain important brain functional sites of single infarction may lead to dementia. Dementia is related to the lesion site. The thalamus, horns, frontal and marginal systems are closely related to dementia. For example, bilateral thalamic and thalamic lesions can form thalamic dementia, which is rare in clinical practice. Different types of cerebrovascular diseases have different pathological changes, and the clinical manifestations of dementia are not the same.

In addition, cerebrovascular disease is not the only cause of dementia. Some studies have found that many patients have dementia related to neurodegeneration, but the clinical manifestations are not obvious. They are in the subclinical stage. Once cerebrovascular disease occurs, dementia can occur more rapidly. The clinical manifestations of the syndrome, the pathology is mixed dementia.

Vascular dementia prevention

First, pay attention to regular visits: patients with cerebral infarction should go to the hospital regularly, conduct regular physical examinations, actively control blood pressure under the guidance of doctors, control blood pressure within the ideal range, and actively treat high risk factors such as diabetes and hyperlipidemia. .

Second, pay attention to diet adjustment: patients should quit smoking, abstain from alcohol, limit eating animal fat or foods with high cholesterol, eat more vegetables, fruits, eat some foods containing iodine, control sugar and salt intake, eat Egg yolk and soybean rich in lecithin, because choline is the carrier of cranial nerves, it is the key substance that determines the strength of memory; and phospholipid is an excellent emulsifier, it is a scavenger of blood vessels, which can improve and prevent arteriosclerosis. Eliminate cerebral infarction.

Third, pay attention to regulating mood: emotional instability is one of the important factors inducing dementia in patients with cerebral infarction. After the stroke, the patient begins to understand the disease he is suffering from, and is afraid of suffering from the pain of the disease. Therefore, the family should be more Talk to the patient, explain it carefully, reduce the fear of the patient through the example of a good prognosis, establish the confidence to overcome the disease, enable them to correctly understand the condition, eliminate the psychological burden, enhance the belief in life, maintain the patient's emotional stability, prevent the occurrence of dementia Play a very important role. Family members participating in recreational activities should create conditions and engage in as many recreational activities as possible to attract the attention of patients and eliminate their sense of loneliness, such as playing simple board games, listening to music, watching burlesque and so on.

Fourth, pay attention to life adjustment: we must rationally arrange the patient's daily life, cultivate a variety of hobbies and interests, pay attention to intellectual training. Qinqi calligraphy and painting can all cultivate sentiment and delay brain aging. To ensure adequate sleep, prevent excessive fatigue and avoid recurrence of small strokes.

Vascular dementia complications Complications depression urinary tract infection acne

Patients often have autonomic dysfunction, depression, and abnormal mental behavior. In addition, complications such as secondary pulmonary infection, urinary tract infection, and hemorrhoids should be noted.

Symptoms of vascular dementia Common symptoms Anxiety suspicion Mesh-like dementia Irritability ocular alzheimer's depression Cognitive dysfunction Personality change cerebral weakness syndrome

Mainly include: early symptoms, symptoms and signs of the local nervous system, and symptoms of dementia.

1. Early symptoms: Long incubation period, generally not easy to be discovered early and not valued, can be divided into two obstacles:

(1) Brain Debilitating Syndrome: According to the classification of ICD-10, it is called organic emotional instability (debilitating) disorder (ICD-10, 1992).

This mental disorder can occur as the earliest symptom, occurring in the asymptomatic phase of cerebral arteriosclerosis, often accompanied by emotional fragility, anxiety and depression, often misdiagnosed as neurasthenia, lasting for a long time, even for several years For a long time, after the onset of TIA, the symptoms will gradually worsen. There are no obvious signs of focal nervous system in this period. The brain-debilitating syndrome can also be used in the recovery phase of stroke, longer-term, light and heavy. In the whole course of cerebrovascular disease.

Its main symptoms:

1 affective disorder: typical symptoms, manifested as persistent emotional instability, emotional vulnerability, ability to restrain emotional expression is significantly weakened, severe emotional incontinence, unable to control emotional response, without obvious trauma or weak stimulation Down, the performance is easy to hurt, easy to irritate, irritating, the patient is willing to restrain emotions, but often can not restrain, I feel very distressed.

2 various physical discomfort symptoms: These symptoms are often manifested as the main body of the patient's diagnosis and treatment.

Headache: full headache, tightness, with the occiput, the double ankle, the forehead, turn the head, and increase the force when suffocating.

Dizziness: more often when the head is turned or tilted back and forth, may be caused by vertebral artery compression, vertebral basilar artery transient cerebral ischemia; dizziness, with tinnitus and hearing loss, may be caused by vestibular artery ischemia, Limb numbness, walking to the side of the sense of tilt, vertigo, muscle tremors and other symptoms often appear.

Sleep disorders: mainly insomnia, sleep is difficult, sleep time is reduced, a small number of patients are drowsy during the day, the symptoms are anxious, and it is not uncommon to take hypnotics.

3 mild attention is not concentrated, thinking is slow, work efficiency is declining, initiative is declining, memory is declining, especially learning new knowledge is difficult, near-forgetting is more obvious, patients have self-knowledge, sometimes with anxiety symptoms, and seeking treatment .

When the symptoms are mild, they are often not taken seriously. Because of the often associated hypertension, the nervous system and laboratory tests should be performed to clearly identify evidence of cerebral arteriosclerosis, such as fundus arteriosclerosis, small infarcts of skull CT, etc. However, the symptoms and signs of no positive nervous system can not negate the diagnosis of cerebral arteriosclerosis.

(2) Mild cognitive impairment: At present, this disorder is still controversial. It can be considered that this symptom occurs in the early stage of cerebral arteriosclerosis, and the cognitive impairment does not reach the severity of dementia, with the symptoms of cerebral arteriosclerosis. Better (the establishment of the collateral circulation, etc.), the symptoms have also improved significantly.

The main feature is a decline in cognitive function, which is manifested in:

1 memory impairment: manifested in the difficulty of learning new knowledge, new things, when the patient is tested for memory, it can be found that when the patient recalls words or objects, the memory declines, mainly due to near memory impairment, but due to patient self-awareness , will try to find ways to compensate, life self-care ability, social skills and understanding, judgment ability can maintain good state for a long time.

2 Attention Distraction: Cannot concentrate, showing a decline in the ability to focus on a particular job.

3 Reasoning and abstract thinking ability reduction: manifested as the patient's new things, the ability to understand and respond to new situations, the ability to solve problems is reduced, and the initiative to participate in social activities declines.

4 language use ability decline: the performance of the patient in the language exchange, the understanding of decline, active conversation can not find the right vocabulary to express their own thinking, is an expressive language dysfunction, sometimes simple conversation No abnormalities, more complicated communication, or longer conversations will reveal that patients have mild obstacles in their ability to express and understand language. Sometimes there are many more detailed descriptions when there is no suitable vocabulary. To replace the phenomenon of specialized vocabulary.

5 visual spatial dysfunction: the patient can not completely correct the relationship of visual space, the confirmation of this symptom can be applied to the patient to draw geometric figures to check whether there is spatial perception dysfunction.

Mild cognitive impairment can be evaluated and measured using a quantitative cognitive assessment work scale. The commonly used scales include neuropsychological tests, short mental state tests, etc., which can be used to determine abnormalities and severity.

Mild cognitive dysfunction persists for no less than 2 weeks, and there must be a conscious disorder. Some scholars believe that if mild cognitive impairment persists, it should be considered as an early symptom of dementia, but it is determined to be mildly recognized. At the time of the knowledge of the disorder, the patient did not reach dementia, and there was a clear distinction from dementia.

2. Localized neurological symptoms and signs: This symptom and sign is a neurological symptom and sign of brain damage secondary or subsequent to cerebrovascular disease. Different neurological symptoms and signs may occur due to different parts of the cerebral vascular injury. In general, lesions located in the left cerebral hemisphere cortex may have aphasia, disuse, loss of reading, loss of writing, miscalculation, etc.; cortical lesions located in the right cerebral hemisphere may have visual dysfunction; located in the subcortical nucleus and Conductive beam lesions, there may be corresponding movements, sensations and extrapyramidal disorders, compulsory crying, pseudobulbaric palsy symptoms, and occasional psychotic symptoms such as hallucinations, self-speaking, silence or stupor When there is an obstacle in the blood supply area of the posterior cerebral artery, ipsilateral hemianopia, spatial loss of recognition and lack of self-knowledge can occur (Tong Kaijin, 1998).

Binswanger type of encephalopathy, not only pseudo-bulbaric paralysis, slow movement, ataxia, unclear speech, with convulsions and mandatory crying, etc., may also have mild pyramidal tract signs, extrapyramidal signs or cerebellum Symptoms, etc.

A large area of cerebral infarction dementia is more acute, and the condition is serious. Even if the survivors are rescued, most of the severe neurological symptoms and signs, such as bedridden, paralysis, loss of self-care ability, and dementia symptoms are more serious.

Due to brain stem disease, thalamic dementia may have difficulty in vertical gaze and other midbrain and pons, but the symptoms of exercise are not obvious.

In general, the above symptoms and signs of the nervous system, after recurrent cerebrovascular disease (especially multiple cerebral infarction dementia), increased more than once, dementia also gradually worsened, from localized dementia to general dementia.

Dementia

(1) Near memory impairment (early): The early core symptom of VD dementia is memory impairment, which is characterized by memory impairment and near memory impairment. Late memory impairment is characterized by memory impairment. For a long period of time, my self-knowledge is good, I know that my memory is declining, I am easy to forget things, I am always forgetting the West, in order to prevent forgetting, I often prepare memos, and some patients have anxiety or depression. Treatment, another symptom of VD dementia in the early stage is that there is no way to speak, no central point, and other phenomena (pathological description). Some patients show that they forget to type and forget which one to choose. Sudden stoppage (fluent aphasia), although the patient has memory impairment in this period, but the daily living self-care ability, comprehension, judgment and etiquette for people to receive and handle the surrounding things, the habits are maintained in good condition, and the personality remains good, so Known as localized dementia or lacular dementia, vascular dementia is the outcome of cerebrovascular disease, and its progression progresses. Significant volatility, ladder-like course, sometimes a longer-term stable disease stage, if established, dementia and memory disorders collateral circulation and other symptoms will appear some improvement.

(2) Mental disorders: During the progression of dementia, some patients may develop psychotic symptoms such as paranoid symptoms, paranoia, relationship delusions, and delusions of delusions. On the basis of memory disorders, they may also be stolen. Poverty delusions, etc., some patients have delusions, and the recovery of sexual desire is not uncommon. Under the domination of delusions, there are corresponding wills and behavioral obstacles. In the development of dementia, emotional activities are gradually changing, from the early emotional fragility, Emotional disorders such as anxiety and depression gradually develop into emotional indifference, indifferent, slow, euphoric, emotional out of control, compulsory crying and so on.

As the symptoms of dementia become more and more serious, some patients have hallucinations, delusions, orientation, cognitive function can also be significantly reduced, emotions become indifferent, will decline significantly, when there is euphoria or compulsory laughter, in behavior and Personality has gradually changed accordingly, such as becoming selfish, embarrassing, collecting waste, aimless jealousy, life gradually becomes unable to take care of themselves, I dont know how to change clothes with the seasons, I dont know how to keep warm, I dont know how to do housework, I dont know my house. Lost, behavioral problems, such as fire, running water, can not take care of themselves, etc., do not know acquaintances, do not know relatives, or even know themselves in the mirror. If the symptoms of dementia can be aggravated, the late stage is severely demented. Most patients have localized neurological symptoms and signs, such as pseudobulbaric paralysis, hemiplegia, aphasia, loss of recognition, misuse, seizures. , urinary incontinence, pyramidal tract signs, extrapyramidal and cerebellar damage.

(3) multi-infact dementia (MID): the disease is caused by micro-emboli of the external cerebral artery (carotid or vertebral artery) plaque or ischemia caused by the white matter center of the brain, most of the small infarction Caused by the stove, it is named as multiple infarct dementia, the cause is due to cerebral arteriosclerosis, thickening of the cerebral artery wall, narrow lumen, resulting in insufficient blood supply to the brain tissue, hypoxia, hemorrhage and softening, from the extracranial artery Embolism is the main cause of multiple infarction. Microinfarction caused by micro-emboli of atherosclerotic detachment only leads to transient ischemic attack (TIA) or small stroke, which does not cause dementia, if embolus is caused Lacuna lesions >0.5 ~ 1.5cm3, will develop into dementia, pathologically visible localized or diffuse ventricle enlargement, narrowing of the cerebral gyrus, softening lesions or hemorrhagic foci of varying sizes in the cerebral cortex or subcortex, mirror Diffuse neuronal degeneration and glial cell hyperplasia can be seen, especially around the blood vessels. In addition, the occurrence of mental disorders is related to their pre-existing personality characteristics, genetic quality, environmental factors and the functional state of the body at the time. .

The incidence of this disease in Europe and the United States is lower than Alzheimer's disease, accounting for only 10% of senile dementia, but Japan is estimated to be as high as 50% to 70%; in China, MID is more than AD, according to Shanghai data, VD patients It accounts for 1% of inpatients in mental hospitals.

The disease occurs mostly in the 50 to 60 years old, and the number of people over 40 years old is gradually increasing. Men are more common and the onset is more urgent. Most patients have high blood pressure, high blood fat, cerebral arteriosclerosis, diabetes and cerebrovascular accident history. deterioration.

In the early stage, the main manifestations were neurasthenic syndrome, and some patients first experienced emotional changes (emotional instability, fragility and irritability) or mild personality changes (good quarrels, nervousness), and then the main memory disorder Memory impairment, emotional instability, increased irritability, and even emotional emotion incontinence or mandatory crying, but also depression, anxiety and suspicion or delusion, but often can detect their own Some obstacles, have some self-knowledge, and try to make up for it or take the initiative to seek medical treatment. People can still maintain certain etiquette when contact with people, so the personality is relatively complete, the late self-control ability is lost, personal hygiene can not take care of themselves, dementia is serious, personality declines. It is difficult to distinguish from Alzheimer's disease. Before entering the late stage, although there are intelligent obstacles such as comprehension ability, its computational ability and critical ability are still good. It is called partial dementia or "net-like dementia". In the onset of a cerebrovascular accident, it may present with confusion, accompanied by behavioral disorders and hallucinations, delusions and other symptoms. Obvious personality changes and mental retardation, in general, a stroke episode 1 time, its personality or intelligence disorder increased 1 time, laboratory examination EEG is often abnormal, cerebrospinal fluid may have a slight increase in protein, cerebral blood flow It can be seen that the vascular elasticity is poor and the resistance is increased. The course of MID is characterized by a so-called step-like process in which the jump is intensified and the incomplete mitigation is alternated. The course of disease can last for several years, even more than 10 years, and more deaths in the heart and kidney function. Depletion.

In a number of strokes (including cerebral thrombosis, cerebral hemorrhage and cerebral embolism) or due to a large amount of cerebral hemorrhage, a rapid mental disorder, called acute cerebrovascular disease caused by mental disorders, its clinical manifestations are consciousness disorders, forgetting synthesis Symptoms, psychotic symptoms (illusions, delusions, etc.) and depression or neuropathic disorders are the main manifestations, generally no mental retardation or only mild intellectual disability, about half of patients can return to the degree of independent living, the prognosis is better, The acute phase treatment of this disease is mainly for cerebrovascular accidents, and various rehabilitation measures can be taken for stroke sequelae.

Examination of vascular dementia

1. Laboratory tests that meet the common cerebrovascular disease or other physical diseases (hyperlipidemia, diabetes, etc.), there are currently no specific sensitive laboratory tests for mental disorders.

2. Psychological laboratory examination: Psychology examination is an important method to diagnose the severity of dementia and dementia. In recent years, China has introduced and revised many internationally simple and rapid screening tools, diagnostic validity, sensitivity and specificity. Both are high and are briefly summarized as follows:

(1) Mini Mental State Examination (MMSE): Prepared by Folstein in 1975 to assess the scoring criteria. If the answer or operation is correct, record "1", the error is "5", refuse to answer or say no. Record "9" or "7", the main statistics of the "1" project sum (MMSE total score), the range is 0 ~ 300 international standard 24 is divided into critical values, 18 ~ 24 for mild dementia, 16 ~ 17 for moderate Dementia, 15 is divided into severe dementia. China has found that the critical value is different due to different educational levels; illiterate is 17 points, primary school (educational years 6 years) is 20 points, and middle school and above is 24 points.

(2) Hasegawa Dementia Scale (HDS): Developed by Hasegawa Kazuo in 1974, a total of 11 projects, including orientation (2 items), memory (4 items), common sense (2 items), Calculate (1 item), remember the named memory (2 items).

The scale uses the positive score method, the full score is 32.5 points, the original author's critical value is: dementia 10.5 points, suspicious dementia 10.5 ~ 21.5 points, edge state 22.O ~ 30.5 points, normal 31.0 points, can also The normal value is divided according to the degree of education: illiterate 16 points, primary school < 20 points, secondary school < 24 points.

(3) Activity of Daily Living Scale (ADL): Developed by Lawton and Brody in 1969, mainly used to assess the daily living ability of subjects.

The ADL is divided into 14 items and the score is 4:

1 You can do it yourself;

2 is somewhat difficult;

3 need help;

4 can not do, 64 points full score, total score 16 points is completely normal, > 16 points have different degrees of functional decline, single item 1 is divided into normal, 2 to 4 points function is reduced, there are 2 or more than 3 Or the total score 22 is the critical value, suggesting that the function has significantly reduced, the conventional total score in China is 18.5 ± 5.5.

3. Imaging examination: CT and MRI showed consistent with cerebrovascular disease, which was consistent with the results of concurrent cerebrovascular diseases (such as cerebral hemorrhage, cerebral infarction or cerebral thrombosis, cerebral embolism, cerebral arteriosclerosis, etc.).

4. Hachinski (1974) The total score of the ischemic index score (HIS) is more than 7 points.

5. Electrophysiological examination: such as EEG, negative correlation evoked potential P300 analysis.

Diagnosis and differentiation of vascular dementia

diagnosis

There are many classifications and diagnostic criteria. According to the diagnostic points of ICD-10: the premise of diagnosis is dementia. The damage of cognitive function is often unbalanced, so there may be memory loss, intelligent damage and signs and symptoms of focal nervous system. To make the diagnosis more likely, for some cases can only be diagnosed by CT or finally neuropathological examination, ICD-10 points out that the characteristics are: high blood pressure, carotid murmur, emotional instability with transient depression, crying Or explosive laughter, transient turbidity or convulsions, often exacerbated by further infarction, and the personality remains relatively intact, but some patients may have obvious personality changes, such as apathy, lack of control or original personality characteristics, Such as self-centered, paranoid or irritating.

In the revised version of the Chinese Mental Disorders Classification and Diagnostic Criteria (CCMD-II-R), the definition is: more often in the middle-aged and old age, often with the deterioration of the intelligent step, the main manifestation of carotid endometrial atherosclerosis The microemboli is detached, causing small branch infarction of the brain artery. Therefore, the patient may have a history of transient ischemic attack, such as transient convulsions, aphasia or visual impairment. The brain tissue has multiple cavities, and the infarct is generally small. The CT examination revealed multiple scattered low-density areas.

According to the diagnostic criteria of CCMD-II-R, it should meet the diagnostic criteria for mental disorders caused by cerebrovascular disease. The onset is slow, the course of disease is fluctuating or stepwise, but the general trend is progressive. First, evidence of cerebrovascular disease should be available. For example, multiple ischemic stroke episodes, multiple transient ischemic attacks, more than a few months of disease and signs of localized neurological damage, and mental disorders as the main clinical manifestations, such as intelligent defects, and Severity is enough to hinder work, study and daily life; short-term memory impairment, often forgotten about recent events; abstract generalization ability, significant judgment ability or high-grade cortical dysfunction, such as aphasia, misuse, loss of recognition, calculation and composition Difficulties, etc.; there may be obvious personality changes, such as head CT and MRI showed multiple luminal lesions, softening lesions, localized brain atrophy and ventricular enlargement, EEG often showed focal slow waves.

Differential diagnosis

The so-called dementia is not a disease unit, but a syndrome, many diseases such as Alzheimer's disease dementia, Pick disease, Parkinson's disease, Huntington's disease, dementia caused by endocrine and metabolic disorders (such as Addison's disease, Cushing disease, hypothyroidism or hyperactivity, etc., dementia caused by hypoxia (such as carbon monoxide poisoning, etc.), dementia caused by brain infection (such as encephalitis, meningitis, neurosyphilis, etc.), others such as brain tumors, normal Pressure hydrocephalus can have clinical symptoms of dementia. In addition, schizophrenia degenerative type, pseudo-dementia with clinical manifestations of senile depression should be distinguished from this disease.

1. Alzheimer's disease dementia Alzheimer's disease is slow, is invasive, the course is chronic progressive deterioration, early no symptoms, lack of understanding of memory loss and mental impairment, emotional apathy, euphoria, There are often no localized symptoms and signs of the nervous system. After the disease progresses, muscle atrophy, myoclonus, etc. may occur, and focal symptoms are less. CT shows symmetrical sulcal widening and ventricular enlargement, which can be distinguished.

It is easier to identify early symptoms, but it is difficult to identify in advanced stage. In particular, a small number of patients are mixed with vascular dementia and Alzheimer's disease dementia, ie, mixed dementia (MD), and differential diagnosis is difficult.

In general, it can be identified from the following aspects:

(1) Age of onset: The age of onset VD is earlier than AD, and it is more common in 50 to 60 years old.

(2) The form and course of the disease: Most of the VD is a slow onset, which may have acute onset, especially in the case of stroke, the symptoms are obviously aggravated, the course of the disease is fluctuating, the step is worse, and the incidence of AD is extremely slow, which is latent.

(3) Early symptoms: VD early symptoms are obvious, such as headache, dizziness, limb numbness, memory loss, insomnia, etc., often accompanied by anxiety or depression, etc., AD has no early symptoms.

(4) Psychiatric symptoms: Early symptoms of dementia are different. AD has no cognitive ability for memory loss and mental impairment, while VD has self-knowledge, and judgment, understanding and abstract generalization ability, personality can be maintained well for a long time. AD patients generally have apathy or euphoria, while VD is mostly emotionally fragile, emotionally unstable or depressed, with emotional out of control in the late stage (mandatory crying), and some patients have hallucinations.

(5) Limited symptoms and signs of the nervous system: VD can be seen in the early signs of cerebrovascular disease, may also be associated with Parkinson's symptom group, walking disorder, pseudobulbar palsy, etc., according to different lesions, different focal symptoms Early AD often has no symptoms and signs of nervous system limitation. After the disease progresses, muscle atrophy, myoclonus, etc. may occur, and focal symptoms are less.

(6) Systemic diseases: Most cases of VD with hypertension, diabetes, hyperlipidemia, etc., AD generally have no special combined disease.

(7) CT findings: MID CT can be seen in multiple small and medium-sized low-density areas. CT of Binswanger type encephalopathy shows enlarged ventricle, white matter low-density area around the ventricle, and CT of AD is symmetrical sulcal widening and ventricular enlargement. There is no significant change in the initial stage, and it is significant as the disease progresses. In order to identify VD and AD, Hachinski (1974) ischemic index score table (HIS) is widely used in clinical practice. This table consists of 13 items. The determination method is simple, the total score is added, VD: the total score is above 7 points; the total score of AD is below 4 points.

In recent years, it has been revised by Loeb et al. to improve the ischemic score sheet (1983) (Yamada Tatsuo et al., 1988), consisting of 6 items, total scores added, VD: total score 5-9 points; AD : 0 to 2 points.

The above data can be used as a secondary differential diagnosis.

According to autopsy, 10% to 15% of dementia cases have both cerebrovascular disease and Alzheimer's disease, which is mixed dementia. If there is evidence that both exist at the same time, the next two diagnoses should be made. The disease precedes Alzheimer's disease, and the clinical diagnosis of the latter is often impossible.

In recent years, repeated CT or MRI examinations of dementia patients more than half a year have revealed more mixed dementia than the first CT or MRI diagnosis of vascular dementia (Cheng Zhengyi, 1977).

2. Pseudo-dementia in depression: elderly patients with depression often have clinical manifestations similar to dementia, such as decreased memory and intelligence, known as pseudo-dementia, the main clinical manifestations are depressive symptoms, no interest in anything, slow motion , few words, low voice, suicidal ideation and behavior, early symptoms of VD can also be seen depression mood, emotional fragility and anxiety, should pay attention to identification, prevent misdiagnosis of pseudo-dementia into VD dementia, delay treatment opportunities.

Its main identification is as follows:

(1) Onset: The onset of depression is rapid, family members quickly find the onset of the disease, can describe the general onset period, the symptoms progress quickly, there are treatment requirements from the onset of the disease, from the onset to the diagnosis and treatment period is shorter, the incidence of VD Slow, long-term early symptoms are not valued by patients and their families, but in the case of obvious comorbidities, such as high blood pressure or cerebrovascular accidents, symptoms may worsen and cause attention, compared with depression, from the onset The interval between diagnosis and treatment is longer.

(2) Emotional changes: The early symptoms of VD are emotional instability, emotional vulnerability, and low mood often secondary to headaches, dizziness, numbness and insomnia, and other early physical symptoms, to a lesser extent, more with mild Anxiety, generally no suicidal idea, attempt and behavior, the main clinical manifestation of depression is depression, but the patient's conscious memory is poor, stupid, stupid, nothing will be done, etc., detailed inquiry can find out whether it is useful or not , helplessness, hopelessness, etc., have no interest in anything, have suicide or suicide attempts and behaviors.

(3) Cognitive function and intelligent test: During the above cognitive function and intelligent test, it was found that patients with depression stressed that they would not do it, and refused to cooperate in the test, which appeared obvious in the results of the test. Unbalanced features, that is, easy problems will not be done, difficult questions are answered correctly, different topics of the same difficulty level, suddenly correct, and mistakes, VD patients generally conduct comparisons and comparisons, serious, test results and their dementia The problem of high degree of consistency and the same level of difficulty, correctness or error is relatively stable and there is no imbalance.

(4) Localized symptoms and signs of the nervous system: patients with depression without other neurological diseases, generally no neurological localized symptoms and signs, no symptoms of nighttime paralysis, except for slow movements, less words, low voice, no other Physical symptoms, VD is often accompanied by neurological limitations and signs, such as hemiplegia, pseudobulbar palsy, etc., nighttime sputum is not uncommon.

(5) Auxiliary examination: using various auxiliary examinations for identification, such as EEG and brain topographic maps, abnormal results of CT and MRI can clearly indicate the specific change of VD, high amplitude of EEG, sharp wave-like Waves, extensive alpha waves, sudden slow waves, etc.; CT can see abnormal changes in low-density areas of varying sizes, while depression is often identified by the Depression Scale and Dementia Scale, memory and intelligence tools, Certain clinical value.

(6) In the differential diagnosis, it must be considered that elderly people may also be accompanied by hypertension or cerebral arteriosclerosis in depression, and may even be associated with mild cerebral vascular dementia, thus bringing differential diagnosis Difficulties, in the history of the inquiry, whether there is depression or transient cerebral ischemia, the history of stroke, and the speed of treatment are also one of the diagnostic criteria for identification.

3. Dementia and senile amnesia identification: Dementia, whether it is vascular dementia, Alzheimer's disease dementia, and other types of dementia, are pathological changes of brain disease, old age forgetfulness is increasing The physiological changes that occur during the ageing process. Therefore, dementia is a manifestation of disease. There is a specific course of disease, and there are more obvious onsets and course of disease. For example, vascular dementia is characterized by stepwise progression. Slow, and Alzheimer's disease dementia, is a slow onset, a progressive process of aggravation, old age forgetfulness is not a disease, no disease course can be said, in general, with age, the performance of forgetting will also increase.

The main symptoms of dementia are not only memory impairment, but also progressively worsening mental retardation. There are often disorientation disorders, which can be accompanied by various psychotic symptoms such as delusions and emotions, will and behavioral disorders, often in the late stages. Personality changes and behavioral disorders, life can not take care of themselves, eating and drinking often need someone to take care of.

In addition to memory loss, senile amnesia has no mental retardation, no psychotic symptoms and disorientation. If there is no physical illness, self-care and behavior can often remain normal.

As far as memory impairment is concerned, the memory impairment of dementia often results in complete memory loss in the late stage. I dont remember what happened just now. The forgetful old man remembers that this happened, but some of the content cannot be recalled. Sexual memory declines, often recalled after reminding, dementia often occurs after a long memory disorder, fiction or fiction, the elderly forgetfulness does not have this symptom, dementia is the manifestation of brain disease, neurological examination and experiment For room examinations, such as head CT or MRI, most of them may have positive findings. Most of the old-age forgetfulness tests are normal and can be identified.

4. Other

(1) normal pressure hydrocephalus: the three main signs of the disease are: memory and mental decline, gait instability and urinary incontinence, the incidence is subacute, the disease progresses faster, CT can be enlarged, can be identified, Most of them are in the middle age, some are in the elderly, and it is very difficult to identify clinically in combination with VD, especially in the case of Binswanger type encephalopathy.

(2) hypothyroidism: This is a dementia caused by endocrine disorders, mainly manifested as: lack of initiative, will decline, lethargy, severe coma can occur, most accompanied by: ataxia, nystagmus, optic atrophy, facial paralysis and Neurological symptoms such as hearing loss, examination of thyroid function, such as basal metabolic rate, combined with serum TRH, T3 and T4 results and the application of thyroxine treatment have significant efficacy, that is, can be identified.

The identification of other endocrine and metabolic disorders caused by dementia and vascular dementia is in principle consistent with the above principles. In short, the cause of dementia is determined by detailed and reliable medical history data, and the results of various examinations have been initially determined. Various examination techniques, such as CT, MRI, PET and SPECT, provide a reliable basis for the diagnosis and differential diagnosis of cerebral vascular dementia.

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