Treatment of vascular dementia and vascular cognitive impairment

Objective: In patients with vascular dementia and vascular cognitive impairment, are acetylcholinesterase inhibitors (donepezil, galantamine, and rivastigmine) and N-methyl-D-aspartate (NMDA) receptor antagonists (memantine) effective in improving cognitive function over placebo? Methods: The question was addressed with a structured, evidence-based, clinical, neurologic practice review. Participants included consultant and resident neurologists, clinical epidemiologists, medical librarians, and clinical content experts. A critically appraised topic format was employed, with a clinical scenario, structured question, search strategy, appraisal, results, summary of evidence, commentary, and bottom-line conclusions. Results: Eight relevant systematic reviews and randomized controlled trials were identified and served as the principal sources of information. The best evidence to date revealed that donepezil 5 mg/d [number needed to treat (NNT)=10] was the most effective and best tolerated [number needed to harm (NNH)=50] of the available agents. Galantamine 24 mg/d (NNT=7) was also effective but less well tolerated (NNH=7). Due to insufficient evidence, rivastigmine could not yet be recommended for the treatment of vascular dementia. Memantine appeared to be safe and well tolerated but did not demonstrate effectiveness across all cognitive outcomes and clinical global measures. Conclusion: Acetylcholinesterase inhibitors and NMDA receptor antagonists, in general, displayed promise as treatments for patients with vascular dementia and vascular cognitive impairment. The most effective, evidence-based treatments were donepezil and galantamine.