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Health See other Health Articles Title: Dementia: Think vascular Medscape... Usually when we think of dementia, we tend to think of Alzheimer's disease (AD). Drug companies have spent two decades trying to tweak the products of the apo E4 gene to treat AD, without success. But it doesn't tend to be appreciated that about one-half of all dementia is vascular dementia, the product of small vessel disease. The importance of vascular dementia partly has to do with the fact that - compared to Alzheimer's disase - the risk factors for vascular dementia are more identifiable, more preventable, and more easily caused or worsened by medications, especially those dopamine blockers that cause or worsen metabolic syndrome. A recent large epidemiological study highlights the importance of vascular dementia. In that analysis, diabetes was found to be an important risk factor for dementia. That study examined a national database from Denmark. About 2% of the study population developed dementia, of whom about 11% had diabetes and 26% had depression. About 7% had both depression and diabetes. The risk of dementia was increased 20% by having diabetes, and four times more, 83%, by having depression. If you have both depression and diabetes, the risk of dementia is more than doubled (117% relative increased risk). Depression is a well-known risk factor for dementia, four fold more harmful than diabetes. But diabetes adds another layer of risk, probably through the well-known mechanism of small vessel disease in the brain as a long-term consequence of diabetes. MRI findings often involve white matter abnormalities in such cases of diabetes-related vascular dementia. A key clinical point here is that "depression" often represents manic-depressive illness (MDI), as readers of this blog will appreciate. As I've described many times previously, "manic-depressive illness" is NOT the same thing as "bipolar disorder", but rather before 1980 MDI meant recurrent mood episodes of any kind, manic OR depressive, and thus represents BOTH bipolar disorder and unipolar depression. One consequence of the fact that "depression" often represents MDI is that many patients receive and benefit from "antipsychotics", which are better called "dopamine blockers" since we are not referring to treating delusions or hallucinations here. These agents are increasingly used as some of them are receiving FDA indications for depressive states, bipolar and unipolar. One of the most studied and used of such agents is quetiapine; olanzapine is also FDA indicated for bipolar depression when combined with fluoxetine (Symbyax) and is commonly used in that condition. Both of these agents cause or worsen metabolic syndrome, through the mechanism of directly causing insulin resistance. This effects is direct, immediate, and absolute: it happens in every person who takes these medications. Thus, they have harmful anti-insulin metabolic effects, which, in the long term, can cause clinical diabetes in many persons, as well as hypertension (not to mention weight gain, which indireclty worsens the risks for those conditions as well). Given that treatment response often isn't complete, clinicians should be careful about causing the worst of all circumstances: Depression (which persists somewhat in many persons despite treatment with these agents), and - because of these dopamine blockers - weight gain, diabetes, hypertension, and physiological anti-insulin effects. In short, extensive use of these dopamine blockers increases all the major risk factors for vascular dementia. There are multiple other dopamine blockers available now which do not have these harmful anti-insulin metaboliic effects, including, in the US, the now generic agent ziprasidone, and the soon to be generic aripiprazole. Other newer patented agents will be more available in the coming years: asenapine, lurasidone, iloperidone, cariprazine. If dopamine blockers are used long-term, as they often are; and are given to middle-aged individuals with demographic risk factors for dementia, as they often are; it would make sense for clinicians to be more conservative and more wary about some of the popular but harmful agents of the past. We clinicians have a duty to avoid adding to the burden of risk for vascular dementia, a burden which is already high with the mere presence of mood illness. Studies like the one just cited should influence us to pay more attention to long-term risk factors for serious illnesses like vascular dementia, not just short-term side effects. Post Comment Private Reply Ignore Thread
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