Subcortical Vascular Dementia: Case Study

Original Editor - Jonathan Tam, Bomi Jang, Emily Mulligan, Kiley Praught, Sofia Lamarche, Harrison Mah, Gary Lai Top Contributors - Bomi Jang, Jonathan Tam, Kiley Praught, Emily Mulligan, Sofia Lamarche, Uchechukwu Chukwuemeka, Lucinda hampton, Harrison Mah and Koon Kei Gary Lai

Discussion

B.B. is a 60-year female who was initially diagnosed by a physician with Stage 3 Vascular Dementia Subcortical Subtype (also known as Binswanger’s Disease) and referred to an outpatient neurological rehabilitation centre. She was first admitted to a hospital due to a minor fall 2-weeks ago. Furthermore, it is believed by the PCP that B.B. had suffered a TIA within the past few months but went undiagnosed and untreated. Before present, B.B. was completely independent in all BADLs and IADLs despite living with a sedentary lifestyle and controlled hypertension.

As of late, B.B. has noticed a decrease in her abilities to perform ADLs independently, decreased confidence in balance and strength, and several symptoms of cognitive decline including (but not limited to) memory loss, psychomotor slowness and weakness, and difficulty organizing her thoughts. Although Vascular Dementia is incurable, it would be beneficial for the interprofessional team to manage and prevent complications.

Regarding problems amenable to physical therapy care, it is remarkably important to address B.B.’s lack of confidence in balance by improving balance, strengthening weak muscles that may contribute to impaired balance, and maintaining functional range of motion. Some problems that physiotherapists may not be able to treat but ought to keep in mind include B.B.’s memory impairments, unpredictable changes in mood, behaviour, and personality, and Primary Progressive Aphasia which may cause difficulty communicating with the patient.

Specific to B.B’s treatment plan, the physical therapists will provide her with community-based PT treatment two times per week, primarily focused on improving balance and functional abilities. Following Canada’s Exercise Guidelines for Older Adults (>65), there will be 150 minutes of moderate to vigorous aerobic exercise and two days of strengthening exercises each week in addition to balance training. Strategies employed to improve compliance include the use of serious games and activities that B.B. enjoys such as Tai-Chi.

*talk about pre- and post- outcome measures for this case!*

In conclusion, this case study demonstrates the challenges, impairments, and management interventions that can be used for patients with early stage Subcortical Vascular Dementia. The study also provides evidence of interventions and associated outcome measures that may be beneficial for this population. It is always important to understand problems within the scope of PT practice and when to refer out to other healthcare providers. Lastly, while this case study provides one way of providing treatment to this population, interprofessional teams ought to consider the context of each individual patient and their related goals.

Self-study Questions

1. Which of the following a common symptom in patients with Subcortical Vascular Dementia?

A) Psychomotor slowness 

B) Memory impairments

C) Mood changes 

D) Balance deficits

E) All of the above

2. Based on B.B.’s case, she received a score of 36/56 on the Berg Balance Scale, putting her at risk for falls. In order to improve her balance, what is the best evidence-based intervention that may benefit B.B.’s return to the community?

A) Mental imagery of balancing on one-leg

B) Tai-Chi

C) Tying her lower extremities together to challenge balance with narrower BOS

D) Sitting on a bed with no upper extremity support while the therapist adds external perturbations (e.g. shoves, lean and release, etc.)

3. Which of the following may NOT be an appropriate outcome measure for B.B.’s case in the initial assessment?

A) Community Balance and Mobility Scale (CBMS)

B) Timed Up and Go (TUG) Test

C) Activities-specific Balance Confidence Scale (ABC)

D) 10-metre walk test 

Answers: 1) E 2) B 3) A