Special interest: Care of the elderly

Vascular dementia (VaD) is common. Pure vascular disease may account for 5–20% of all cases of dementia, while mixed dementia, Alzheimer's disease (AD) with VaD, occurs at least as frequently. It is unusually heterogeneous and frequently overlapping and comorbid with other conditions such as stroke, other cardiovascular and cerebrovascular diseases and their risk factors, as well as AD. There is no specific treatment or cure for VaD, but its proximity to other conditions may make it amenable to interventions at various stages of the disease. Most recent research suggests that VaD and AD occupy ends of the same spectrum and share common risk factors. As VaD is closely related to cardiovascular disease, modifying cardiovascular risk factors may assist in its prevention. Cardiovascular risk factors such as hypertension, dyslipidaemia, obesity, smoking and diabetes are closely associated with cognitive impairment, AD, as well as VaD. While hypertension in midlife increases the risk of all-cause dementia including AD, a reduction in blood pressure may occur with the onset of AD. Regular screening of high-risk individuals could help to detect dementia early on and enable appropriate preventive intervention. This could involve pharmacological as well as behavioural modulation of risk factors. Medication for hypertension, diabetes and hypercholesterolaemia is recommended, as treatment reduces the risk of developing cognitive impairment and dementia. Behavioural treatments include enhancing and encouraging cognitive and physical activity, social engagement, smoking cessation and healthy diet, including alcohol reduction. Although smoking and excessive alcohol consumption are so far not directly linked to VaD, they are risk factors for cardiovascular disease and stroke and should be treated as indirect risk factors. It should not be forgotten that depressive illness or symptoms in old people can affect their cognitive function and worsen existing cognitive impairment.

Almost 200 years ago, James Parkinson described a condition with ‘involuntary tremulous motion, lessened voluntary powers,' but with ‘uninjured senses and intellect' that would later be named Parkinson's disease by Charcot. Since then, it has emerged that cognitive impairment is present in a large proportion of patients with Parkinson's disease. Cognitive symptoms in patients with Parkinson's disease are associated with more rapid deterioration and eventually, a two-fold increase in mortality. Patients with cognitive impairment place a greater burden on their care givers and many such patients are admitted to nursing homes. Primary care plays a significant role in the recognition of DLB and PDD. Early recognition and referral to a specialist memory clinic can help to educate the patient about their often worrying symptoms and initiate the relevant treatment. Through the involvement of the multidisciplinary team, appropriate care networks can be set up to provide support and education for both patients and carers.

Brain ageing is generally thought of as atrophy, leading to cognitive deficits and functional impairment.  However,  there are also physiological reductions in cell numbers, connectivity and brain plasticity during the life span that may play an important role in the adjustment of brain function to the changing roles of the individual.