MESSAGE FROM THE PRESIDENT
Message from the previous president Vladimir Hachinski
THE INTERNATIONAL SOCIETY OF BEHAVIOURAL AND COGNITIVE VASCULAR DISORDERS
What is being done
One in three individuals will end up with a stroke, dementia or both1 unless we improve prevention. Moreover, for each person over the age of 65 years who has had a stroke or dementia, two have some cognitive problem short of dementia.2 At the moment, the major emphasis is on the late stages, and the extremes i.e. stroke and dementia. That leaves a neglected majority whose problems are seldom addressed, because they may not be severe enough to prompt medical attention or if the complaints are aired, they may be dismissed as attributable to old age.
Although it is becoming increasingly evident that depression can be associated with certain types of cerebral infarcts and white matter changes, we are yet to work out an anatomy of melancholy and provide a neuroscientific bases for addressing what remains a major problem.
WHAT VAS-COG CAN DO
Most knowledge accrues in pieces but is understood in patterns. Most organizations specialize in areas that themselves get subdivided “ad infinitum”. Vas-Cog may be the only organization that tries to integrate knowledge and understand the broad spectrum of cognitive disorders. It emphasizes the vascular factors, which are potentially treatable and provide means towards preventing, mitigating or delaying all types of cognitive disorders, including Alzheimer disease. Cerebrovascular and Alzheimer disease share the same vascular risk factors.
Focusing on stroke and dementia has been achieved to the relative neglect of the prodromal and intermediate stages. Stroke investigators have little interest in cognition, and dementia investigators even less in stroke.
Even if stroke and dementia investigators did have a reciprocal interest in the two areas, there has been no agreement on common data elements. Dementia criteria can vary in their identification of the same set of patients by a factor of 10!3
Vas-Cog established working groups to try to develop common minimal standards. This endeavor took a leap forward when Dr. Gabrielle Leblanc, Dr. Costantino Iadecola and Dr. Vladimir Hachinski organized a symposium with the leadership, participation or contributions from members of the different working groups of Vas-Cog, so that now exist minimum recommended standards for the whole spectrum of cognitive impairment.4 The advantage of using common data elements is that several provisional criteria can be tested simultaneously and modified many times according to outcomes, as knowledge grows.
The San Antonio Congress in July 11-14, 2007 proved extensive, intensive and very interactive. Through the initiative of Dr. Gustavo Roman, a Declaration of San Antonio was issued calling for the public, the drug industry, government, investigators and patients to become aware of the growing burden of brain disease attributed to vascular injury and to do something about it. (below)
The emphasis needs to shift from effects to causes of cognitive and behavioural disorders. Therein lie the best hopes of treatment and prevention.
It may be time for a trial in prevention and/or delay of cerebrovascular and Alzheimer disease by randomizing family practices and/or communities to usual care or optimal care of vascular risk and protective factors. Vas-Cog has established a working group with the specific task of producing a proposal and discussion paper for publication that outlines the need and means of implementing such a study.
What you can do
1. Join Vas-Cog.
2. After you have joined, have someone else join.
3. Join a working group.
In addition to a working group on prevention, there are working groups on neuropsychology and mechanisms of vascular cognitive impairment. If you have an idea for another working group, please write me with suggestions about the topic and individuals who may lead it.
Advances occur not by breakthroughs alone, but also by many people making small advances cumulatively contributing as much as the few who make major advances. No-one’s work is important simply because it is sophisticated, nor valueless because it is humble. We can all improve what we do. We can all make a difference. Let’s make a difference!
Vladimir Hachinski, MD, FRCPC, DSc
1. Shahadri S, Beiser A, Kelly-Hayes M, Kase CS, Au R, Kannel WB, Wolf PA. The lifetime risk of stroke: estimates from the Framingham Study. Stroke. 2006;37:345-350.
2. Jin YP, Di Legge S, Ostbye T, Feightner JW, Hachinski V. The reciprocal risks of stroke and cognitive impairment in an elderly population. Alzheimer’s & Dementia. 2006;2:171-178.
3. Erkinjunntti T, Kurz A, Gauthier S, Bullock R, Lilienfeld S, Demaraju CV. Efficacy of galantamine in probable vascular dementia and Alzheimer’s disease combined with cerebrovascular disease: a randomized trial. The Lancet. 2002;359:1283-90
4. Hachinski V, Iadecola C, Petersen RC, Breteler MM, Nyenhuis DL, Black SE, Powers WJ, DeCarli C, Merino JG, Kalaria RN, Vinters HV, Holtzman DM, Rosenberg GA, Wallin A, Dichgans M, Marler JR, Leblanc GG. National Institute of Neurological Disorders and Stroke-Canadian Stroke Network vascular cognitive impairment harmonization standards. Stroke. 2006;37(9):2220-41.