Hsu-Ko Kuo, MD, MPH, Department of Geriatrics and Gerontology, National Taiwan University; Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.
Yau-Hua Yu, DDS, DMSc, Department of Medical Research, Veterans General Hospital, Taipei, Taiwan.
Shin-Yu Lien, BS, School of Nursing, Chang Gung University, Taoyuan, Taiwan.
Yi-Der Jiang, MD, PhD, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.

There has been a substantial increase in total cases of diabetes mellitus in industrialized countries among older adults. Diabetes mellitus has been increasingly recognized as a risk factor for cognitive impairment and dementia. This article discusses the epidemiological evidence for diabetes to predict Alzheimer’s disease, vascular dementia, and decline in various domains of cognition. We also address the features of diabetes-related executive dysfunction and its importance in the clinical care of diabetic older adults.
Key words: diabetes mellitus, cognition, Alzheimer’s disease, vascular dementia, frontal executive dysfunction.

Kannayiram Alagiakrishnan, MD, MPH, FRCP(C), Associate Professor, Division of Geriatric Medicine, Department of Medicine, University of Alberta, Edmonton, AB.
Cheryl A. Sadowski, BSc(Pharm), PharmD, Associate Professor, Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, AB.

Cholinergic deficits are seen in the brains of individuals with non-Alzheimer’s dementia. Antidementia drugs such as cholinesterase inhibitors and memantine have showed some cognitive and behavioural benefits in non-Alzheimer’s dementia trials, but more evidence is needed to define their role.
Key words: mixed dementia, cholinesterase inhibitors, Lewy body dementia, Parkinson disease dementia, vascular dementia.

Weerasak Muangpaisan, MD, FRCPT, Assistant Professor, Department of Preventive and Social Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Thailand; visiting fellow, Harris Manchester College, University of Oxford, Oxford, U.K.

Cases of dementia are increasing due to longer life expectancy of the world population. Physicians should be able to recognize common dementia syndromes. After excluding reversible causes of dementia, there are four common dementia syndromes, which are Alzheimer’s disease, vascular dementia, dementia with Lewy body, and frontotemporal dementia. The key points of clinical differences of these dementia syndromes are summarized in this article.
Key words: Alzheimer’s disease, vascular dementia, dementia with Lewy body, frontotemporal dementia, Parkinson’s disease.

Rita Moretti, MD, Clinica Neurologica, Dipartimento Medicina Clinica e Neurologia, Università degli Studi, Trieste, Italy.
Paola Torre, MD, Clinica Neurologica, Dipartimento Medicina Clinica e Neurologia, Università degli Studi, Trieste, Italy.
Rodolfo M. Antonello, MD, Clinica Neurologica, Dipartimento Medicina Clinica e Neurologia, Università degli Studi, Trieste, Italy.

Cerebrovascular disease is a potential cause of vascular dementia. Vascular dementia is not an univocal entity; it encompasses at least four types of dementia: multi-infarct, subcortical, strategic infarct, and posthemorrhage dementia. Vascular dementia does not contain cognitive problems only. There are also noncognitive behavioural alterations. The major noncognitive behavioural situations are depression, anxiety, agitation, delusions, and insomnia. Disorders such as depression, anxiety, and psychosis not only affect the quality of life of a patient but also that of the caregiver. Behavioural disturbances may also contribute to morbidity and are a major cause of institutionalization since they result in inadequate nutrition and sleep and enhance cognitive disruption. Diagnosing depression in the context of vascular dementia is challenging given the overlap of signs and symptoms between depression and dementia. Both disorders can be characterized by apathy and loss of interest, an impaired ability to think, psychomotor agitation, and psychomotor retardation.
Key words: behaviour, subcortical vascular dementia,, vascular dementia, small-vessel dementia.

Elise J. Levinoff, MSc, BSc, University of Ottawa, Faculty of Medicine, Ottawa, ON.

Dementia is a neurological disease that is associated with aging. The incidence and prevalence of dementia is increasing as the population continues to age. The two most common forms of dementia are Alzheimer’s disease (AD) and vascular dementia (VaD). Although these two forms of dementia represent different pathologies and different clinical presentations, they share similar risk factors. It is important to distinguish between the two forms of dementia because of the differing treatments, and because the risk factors for each are often preventable. This article will discuss the classification, risk factors, and diagnosis of AD and VaD, and present distinguishing characteristics between them.
Key words: dementia, Alzheimer’s disease, vascular dementia, stroke, memory.

The accredited CME learning activity based on this article is offered under the auspices of the CE department of the University of Toronto. Participating physicians are entitled to one (1) MAINPRO-M1 credit by completing this program, found online at www.geriatricsandaging.ca/cme

Lonn Myronuk, MD, FRCPC, Member of the Canadian Academy of Geriatric Psychiatry; President, GeriPsych Medical Services, Inc., Parksville, BC.

Progress in basic neuroscience has brought disparate clinical phenotypes of dementia together in categories based on common pathophysiological processes. Degenerative dementias are all proteinopathies featuring abnormal processing and CNS accumulation of different proteins in different neuroanatomic distributions dictating patterns of presentation of clinical symptoms and potential responsiveness to treatment. Alzheimer’s disease (AD) is an amyloidopathy. Dementia with Lewy bodies (DLB), Parkinson’s disease (PD) and multiple system atrophy (MSA) are synucleinopathies. Frontotemporal lobar degeneration (FTLD), progressive supranuclear palsy, and corticobasal degeneration are tauopathies. Vascular dementia (VaD) has been considered a distinct pathophysiologic process yet may exist on a continuum with AD. Currently available dementia treatments are not specific for a single disorder, yet not all dementias are treatment responsive. Exclusion of otherwise treatable depressive disorders and metabolic derangements as well as surveillance for deleterious cognitive effects of medication remain central to the assessment and treatment of the older adult with cognitive complaints. Identification of those syndromes for which certain medications may be contraindicated, as well as those that may be selectively responsive to particular compounds, will continue to increase in importance as our range of therapeutic options widens over the coming years.
Key Words: Alzheimer’s disease, Lewy body, frontotemporal lobar degeneration, vascular dementia, differential diagnosis.

Ging-Yuek Robin Hsiung, MD, MHSc, FRCPC, Assistant Professor, Division of Neurology, Department of Medicine, UBC Clinic for Alzheimer Disease & Related Dementias, University of British Columbia, Vancouver, BC.

Dementia care represents a significant burden to our society. Although we are still far from any cure for dementia, there are several medications available for symptomatic management of Alzheimer’s disease and vascular dementia. These agents not only improve the cognitive and behavioural symptoms of dementia but may also help maintain patients’ functional independence and lessen caregiver stress. There are also a number of clinical trials currently in place to investigate new agents for treatment of Alzheimer’s disease. This article reviews the current medications available for Alzheimer’s disease and vascular dementia, as well as a number of promising agents that are under investigation.
Key words: Alzheimer’s disease, vascular dementia, cholinesterase inhibitors, donepezil, galantamine, rivastigmine, memantine.

Colin P. Derdeyn, MD, Associate Professor, Mallinckrodt Institute of Radiology and the Departments of Neurology and Neurological Surgery, Washington University School of Medicine, St. Louis, MO, USA.

The brain requires the continuous delivery of oxygen and glucose for normal function. Even brief interruption or impairment of this supply can cause permanent injury, most dramatically and catastrophically in the form of stroke. There is emerging data that in addition to stroke, microvascular arterial obstructive disease may be a common cause of dementia. With normal aging, and as an effect of a number of diseases common in older adults such as hypertension, several pathological conditions of the brain vasculature may develop. This brief review will discuss a few common cerebrovascular diseases of older adults and recent data regarding their treatment. These conditions include intracranial aneurysms, atherosclerosis and atherosclerotic stenosis, and vascular dementia.

Key words: intracranial aneurysms, atherosclerosis, stroke, brain vasculature, vascular dementia.

David J. Gladstone, BSc, MD, FRCPC; Lorne Zinman, MD, FRCPC; Jodie Burton, MD; Leanne Casaubon, MD; David Chan, MD; Neil Cashman, MD, FRCPC; Sandra E. Black, MD, FRCPC; Morris Freedman, MD, FRCPC.
From the Division of Neurology, University of Toronto, Toronto, ON.

At the Third Annual University of Toronto (U of T) Behavioural Neurology Clinic Day for residents, fellows and other trainees, presentations were given by faculty members from the U of T Department of Medicine (Divisions of Neurology and Geriatric Medicine) and the Department of Psychiatry. Highlights of this educational event are summarized herein by residents in the neurology training program.
Key words: dementia, diagnosis, fronto-temporal dementia, dementia with Lewy bodies, Creutzfeld-Jakob disease, vascular dementia.

Chris MacKnight, MD, MSc, FRCPC, Division of Geriatric Medicine, Dalhousie University, Halifax, NS.

Introduction
Vascular dementia is common, and currently there is no accepted therapy aimed at the cognitive symptoms. Prevention of further strokes is, of course, well established.¹ Evidence is accumulating that the cholinesterase inhibitors, proven therapy in Alzheimer disease (AD), may also be of use in vascular dementia (VaD). This paper will summarize that evidence.

Epidemiology of Vascular Dementia
Vascular dementia can be diagnosed when there is a high degree of suspicion that cognitive impairment and stroke are related. Various criteria exist, which unfortunately do not overlap to any great extent, but all share several features.² These include: the presence of stroke, either clinical or found on neuroimaging; the presence of focal neurologic signs, such as asymmetric power or a positive Babinski response; and a characteristic course, with a sudden onset or stepwise progression. For the highest degree of confidence in the diagnosis, a temporal relationship between the stroke and the dementia is required.

In most surveys of older adults, vascular dementia is the second most common cause of dementia in the community, after AD. In Canada, the prevalence of VaD is 1.5% in people 65 and over, and 5.1% for AD.³ Other surveys have found similar values.