The cholinergic approach for the treatment of vascular dementia: evidence from pre-clinical and clinical studies.

The involvement of an impaired cholinergic neurotransmission in the pathophysiology of cognitive impairment occurring in vascular dementia (VaD), as well as the possibility of treating it by stimulating cholinergic neurotransmission was reviewed. Pre-clinical data suggest that similarly as documented in dementia disorders of neurodegenerative origin, a cholinergic deficit is involved in the pathophysiology of cognitive impairment of vascular origin. In the past, clinical trials have evaluated cholinergic precursors such as lecithin, citicoline and choline alphoscerate. More recent investigations have assessed acetylcholinesterase (AChE) and cholinesterase (ChE) inhibitors such as donepezil, rivastigmine and galantamine. In general, treatment with citicoline, choline alphoscerate, as well as with AChE and ChE inhibitors induced favourable effects on cognitive function in dementia disorders of vascular origin. These positive results should be regarded with caution due to the small number of patients included in controlled clinical trials using cholinergic precursors and to the limited number and sample size of trials with AChE and ChE inhibitors. Among compounds investigated, choline alphoscerate was well tolerated, improved cognitive function in VaD patients to a better extent than citicoline and to similar or better extent than other more recently developed drugs. This particular profile would justify reconsideration of the compound in larger controlled clinical trials for the treatment of cognitive dysfunction associated with dementia disorders of vascular origin.