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Vascular Dementia Differs From Alzheimer’s Disease

Dear Dr. Roach: My husband, age 84, has vascular dementia. How does this differ from other forms of dementia? What is the time frame for progression of this illness? — P.M.

Answer: Vascular dementia, also called multi-infarct dementia, is caused by poor blood flow to the brain. This causes many “mini-strokes,” which, early on, can be overlooked.

High blood pressure, high cholesterol and diabetes all predispose one to develop this condition. The dementia caused by vascular disease may look much like Alzheimer’s disease, but the progression tends to be different. In Alzheimer’s disease, dementia progresses almost imperceptibly, but in vascular dementia, there usually is a sudden worsening, followed by a time of stability. A major goal in vascular dementia is to prevent the next stroke through meticulous care of the underlying medical causes, and usually with aspirin or prescription medications to prevent a blood clot in the brain.

Dear Dr. Roach: I am an otherwise healthy 81-year-old suffering from gynecomastia. I play tennis twice a week and work out. My weight is 172, and I am 67 inches tall. The diagnosis followed via mammogram and ultrasound. Both breasts are affected, but the right one is worse, with swelling and significant tenderness when touched. My endocrinologist ran a full battery of hormone tests and all show normal for a man my age. There was some suspicion that an allergy med (loratadine) was the cause, but the breast enlargement has continued. My meds are lisinopril and hydrochlorothiazide for blood pressure, and simvastatin and clopidogrel for cholesterol.

My questions: Since breast cancer and low testosterone have been ruled out, what other test should be taken to determine the cause of this problem? Is it reversible? Other than surgery, are there any suggestions? — R.S.

Answer: Gynecomastia is a benign enlargement of the male breast. It is not uncommon, and it can happen at any age. Puberty probably is the most common time, but it certainly can happen in middle-age and older men.

Your endocrinologist has done everything right, as far as I can tell. Looking at medication use is important, since in healthy men it is one of the most common causes. Making sure it isn’t breast cancer is critical, and a mammogram may be necessary. I have had three male patients with breast cancer.

If the tests are all normal, as in your case, then no cause is usually ever found. Sometimes, gynecomastia goes away by itself, and if it isn’t bothering you, it doesn’t have to be treated. However, either because of appearance or because of tenderness, many men wish to be treated. There is medication treatment for gynecomastia, and it is most effective if begun within a year or two after it appears. For adults, tamoxifen and dihydrotestosterone have been effective for gynecomastia, but neither is approved by the Food and Drug Administration for this purpose.

Surgery is very effective when performed by an experienced cosmetic surgeon, and often includes both direct surgical removal of the glandular tissue and liposuction.

Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu or write to P.O. Box 536475, Orlando, FL 32853-6475.