Better Health While Aging

Practical information for aging health & family caregivers

Cerebral Small Vessel Disease:
What to Know & What to Do

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Signs of cerebral small vessel disease. From Inzitari et al, BMJ. 2009 Jul 6;339:b2477. doi: 10.1136/bmj.b2477

This article is about the most common aging brain problem that you may have never heard of.

While leading a fall prevention workshop a few years ago, I mentioned that an older person’s walking and balance problems might well be related to the presence of “small vessel ischemic changes” in the brain, which are very common in aging adults. (This is also called “white matter disease.”)

This led to an immediate flurry of follow-up questions. What exactly are these changes, people wanted to know. Do they happen to every older adult? Is this the same as vascular dementia? And how they can best help their parents with cognitive decline?

Well, these types of brain lesions don’t happen to every older person, but they do happen to the vast majority of them.  In fact, one study of older adults aged 60-90 found that 95% of them showed signs of these changes on brain MRI.

In other words, if your older parent ever gets an MRI of the head, he or she will probably show some signs of these changes.

So this is a condition that older adults and families should know about. Furthermore, these changes have been associated with problems of consequence to older adults, including:

  • Cognitive decline,
  • Problems with walking or balance,
  • Strokes,
  • Vascular dementia.

Now, perhaps the best technical term for what I’m referring to is “cerebral small vessel disease.” But many other synonyms are used by the medical community — especially in radiology reports. They include:

  • White matter disease
  • Small vessel ischemic disease
  • Brain lesions
  • Periventricular white matter changes
  • Perivascular chronic ischemic white matter disease of aging
  • Chronic microvascular changes, chronic microvascular ischemic changes
  • Chronic microvascular ischemia
  • White matter hyperintensities
  • Age-related white matter changes
  • Leukoaraiosis

In this post, I will explain what all older adults and their families should know about this extremely common condition related to the brain health of older adults.

In particular, I’ll address the following frequently asked questions:

  • What is cerebral small vessel disease (SVD)?
  • What are the symptoms of cerebral SVD?
  • How is cerebral small vessel disease related to vascular dementia and cerebrovascular accidents?
  • What causes cerebral SVD?
  • How can cerebral SVD be treated or prevented?
  • Should you request an MRI if you’re concerned about cerebral SVD?

I will also address what you can do, if you are concerned about cerebral SVD for yourself or an older loved one.

What is cerebral small vessel disease?

Cerebral small vessel disease (SVD) is an umbrella term covering a variety of abnormalities related to small blood vessels in the brain. Because most brain tissue appears white on MRIs, these abnormalities were historically referred to as “white matter changes” or “white matter disease.”

Per this medical review article, specific examples of cerebral SVD include “lacunar infarcts” (which are a type of small stroke), “white matter hyperintensities” (which are a radiological finding), and “cerebral microbleeds” (which means bleeding in the brain from a very small blood vessel).

In many cases, cerebral SVD seems to be a consequence of atherosclerosis affecting the smaller blood vessels that nourish brain tissue. Just as one’s larger blood vessels in the heart or elsewhere can accumulate plaque, inflammation, and chronic damage over the years, so can the smaller blood vessels.

Such chronic damage can lead the small blood vessels in the brain to become blocked (which starves brain cells of oxygen, and which we technically call ischemia), or to leak (which causes bleeding, which we call hemorrhage and can damage nearby brain cells).

When little bits of brain get damaged in these ways, they can change appearance on radiological scans. So when an MRI report says “white matter disease,” this means the radiologist is seeing signs that probably indicate cerebral SVD.

(Note: In this podcast episode, a UCSF brain health expert explains that although cerebral small vessel disease is probably the most common cause of white matter changes in older adults, it’s not the only condition that can cause such changes. )

Such signs of SVD may be described as “mild”, “moderate,” or “severe/extensive,” depending on how widespread they are.

Here is an enlargement of a good image, from the BMJ article “Changes in white matter as determinant of global functional decline in older independent outpatients.”

MRI brain cerebral small vessel ischemic disease
From Inzitari et al, BMJ. 2009 Jul 6;339:b2477. doi: 10.1136/bmj.b2477.

What are the symptoms of cerebral small vessel disease?

The severity of symptoms tends to correspond to whether radiological imaging shows the white matter changes to be mild, moderate, or severe.

Many older adults with cerebral SVD will have no noticeable symptoms. This is sometimes called “silent” SVD.

But many problems have been associated with cerebral SVD, especially when it is moderate or severe. These include:

  • Cognitive impairment. Several studies, such as this one, have found that cerebral SVD is correlated with worse scores on the Mini-Mental State Exam. When problems with thinking skills are associated with SVD, this can be called “vascular cognitive impairment.”
  • Problems with walking and balance. White matter lesions have been repeatedly associated with gait disturbances and mobility difficulties. A 2013 study found that moderate or severe cerebral SVD was associated with a decline in gait and balance function.
  • Strokes. A 2010 meta-analysis concluded that white matter hyperintensities are associated with a more than two-fold increase in the risk of stroke.
  • Depression. White matter changes have been associated with a higher risk of depression in older people, and may represent a contributor to depression that is particular to having first-time depression in later life.
  • Vascular dementia. Signs of cerebral SVD are associated with both having vascular dementia, and eventually developing vascular dementia.
  • Other dementias. Research suggests that cerebral SVD is also associated with an increased risk — or increased severity — of other forms of dementia, such as Alzheimer’s disease. Autopsy studies have confirmed that many older adults with dementia show signs of both Alzheimer’s pathology and cerebral small vessel disease.
  • Transition to disability or death. In a 2009 study of 639 non-disabled older persons (mean age 74), over a three-year follow-up period, 29.5% of participants with severe white matter changes and 15.1% of participants with moderate white matter changes developed disabilities or died. In comparison, only 10.5% of participants with mild white matter changes transitioned to disability or death over three years. The researchers concluded that severity of cerebral SVD is an important risk factor for overall decline in older adults.

So what does this all mean, in terms of symptoms and cerebral SVD? Here’s how I would boil it down:

1.Overall, older adults with any of the problems listed above have a high probability of having cerebral SVD.

2. But, many older adults with cerebral SVD on MRI are asymptomatic, and do not notice any difficulties. This is especially true of aging adults with mild cerebral SVD.

3. Older adults with cerebral SVD are at increased risk of developing the problems above, often within a few years time. This is especially true of people with moderate or severe cerebral SVD.

How is cerebral small vessel disease related to vascular dementia and cerebrovascular accidents?

The term “vascular dementia” means having dementia that is mostly due to having had problems with the blood vessels in the brain.

(For more on the definition of dementia and vascular dementia, see here: Beyond Alzheimer’s: Common Types of Dementia in Aging.)

The brain has some large blood vessels; when a person develops a clot or bleed related to a large blood vessel, this causes a major stroke, also known as a cerebrovascular accident.

It is possible to get dementia after a major stroke. However, in older adults, it’s probably more common to develop vascular dementia due to injuries to the small vessels of the brain. But again, as I explained above: not everyone with signs of cerebral small vessel disease ends up developing cognitive impairment or dementia.

What causes cerebral small vessel disease?

This is a topic of intense research, and the experts in this area tend to really nerd out when discussing it. (Read the scholarly papers listed below to see what I mean.) One reason it’s difficult to give an exact answer is that cerebral SVD is a broad umbrella term that encompasses many different types of problems with the brain’s small blood vessels.

Still, certain risk factors for developing cerebral SVD have been identified. Many overlap with risk factors for stroke. They include:

  • Hypertension
  • Dyslipidemia (e.g. high cholesterol)
  • Atrial fibrillation
  • Cerebral amyloid angiopathy
  • Diabetes
  • Smoking
  • Age
  • Inflammation

There is also evidence that Alzheimer’s disease and cerebral small vessel disease frequently co-exist in older adults, and might interact to accelerate cognitive decline.

How can cerebral small vessel disease be treated or prevented?

Experts are still trying to figure out the answers to this question, and research into the prevention of cerebral SVD is ongoing.

Since worsening of white matter disease is often associated with clinical problems, experts are also trying to determine how we might prevent, or delay, the progression of SVD in older adults.

Generally, experts recommend that clinicians consider treating any underlying risk factors. In most cases, this means detecting and treating any traditional risk factors for stroke.

(For more on identifying and addressing stroke risk factors, see How to Address Cardiovascular Risk Factors for Better Brain Health: 12 Risks to Know & 5 Things to Do.)

To date, studies of hypertension treatment to prevent the progression of white matter changes have shown mixed results. It appears that treating high blood pressure can slow the progression of brain changes in some people. But such treatment may be less effective in people who are older than 80, or who already have severe cerebral SVD.

In other words, your best bet for preventing or slowing down cerebral SVD may be to properly treat high blood pressure and other risk factors before you are 80, or otherwise have significant SVD.

Furthermore, experts don’t yet agree on how low to go, when it comes to optimal blood pressure for an older person with cerebral small vessel disease. (This article explains why this has been difficult to determine.)

For now, to prevent the occurrence or progression of cerebral small vessel disease, it’s reasonable to start by observing the hypertension guidelines considered reasonable for most older adults: treat to a target of systolic blood pressure less than 150mm/Hg.

Whether to treat high blood pressure — and other cardiovascular risk factors — more aggressively should depend on an older person’s particular health circumstances. I explain a step-by-step process you can use (with links to related research) here: 6 Steps to Better High Blood Pressure Treatment for Older Adults.

You can also learn more about the research on CSVD and the effect of treating blood pressure here: The relation between antihypertensive treatment and progression of cerebral small vessel disease.

Should you request an MRI if you’re concerned about cerebral SVD?

Not necessarily. In my opinion, older adults should only get MRIs of the brain if the following two things are true:

  1. They are experiencing worrisome clinical symptoms, and
  2. The results of the MRI are needed to decide on how to treat the person.

For most older adults, an MRI showing signs of cerebral SVD will not, in of itself, change the management of medical problems.

If you have high blood pressure, you should consider treatment. If you are having difficulties with walking or balance, signs of cerebral SVD do not rule out the possibility of other common causes of walking problems, such as medication side-effects, foot pain, neuropathy, and so forth.

What if you’re concerned about memory or thinking problems? Well, you probably will find signs of cerebral SVD on an MRI, just because this is a common finding in all older adults, and it’s especially common in people who are experiencing cognitive changes.

However, the MRI cannot tell you whether the cognitive changes you are noticing are only due to cerebral SVD, versus due to developing Alzheimer’s disease, versus due one of the many other dementia mimics. You will still need to pursue a careful evaluation for cognitive impairment. And no matter what the MRI shows, you will likely need to consider optimizing cardiovascular risk factors.

So in most cases, a brain MRI just to check for cerebral SVD is probably not a good idea.

However, if an MRI is indicated for other reasons, you may find out that an older person has mild, moderate, or severe signs of cerebral SVD. In this case, especially if the cerebral SVD is moderate or severe, you’ll want to consider taking steps to reduce stroke risk, and also to monitor for cognitive changes and increased disability.

What to do if you’re worried about cerebral small vessel disease

If you are worried about cerebral SVD, for yourself or for an older relative, here a few things you can do:

  • Talk to your doctor about your concerns. You may want to discuss your options for optimizing vascular risk factors, including high blood pressure, high cholesterol, high blood sugar, smoking, and others. For more on identifying and addressing stroke risk factors, see How to Address Cardiovascular Risk Factors for Better Brain Health: 12 Risks to Know & 5 Things to Do.
  • Remember that exercise, a healthy diet (such as the Mediterranean diet), good sleep, stress reduction, and many other non-pharmacological approaches can help manage vascular risk factors. Lifestyle approaches are safe and usually benefit your health in lots of ways. Medications to treat high blood pressure and cholesterol should be used judiciously.
  • If an MRI of the brain is clinically indicated — or if one has recently been done — ask the doctor to help you understand how the findings may correspond to any worrisome symptoms you’ve noticed. But if you’ve been worried about cognitive impairment or falls, remember that such problems are usually multi-factorial (i.e. they have multiple causes). So it’s best to make sure the doctors have checked for all other common contributors to thinking problems and/or falls.

If you want to learn still more about cerebral small vessel disease, here are some scholarly articles on the subject:

I also recommend listening to this very informative podcast interview, with Dr. Fanny Elahi of the UCSF Memory and Aging Center: 084 – Interview: Understanding White Matter Changes in the Aging Brain.

Note: We’ve hit 300+ comments on this article! So we’re closing comments for this article. Thank you for your interest!

Note: This article has generated a lot of questions from people under age 60. If that describes you, please read below:

  • Please read the article on “Early Cerebral Small Vessel Disease,” the full article is available for free. This describes SVD found in people aged 40-75. In this study, 2-3% of participants in their 40s showed signs of cerebral SVD.
    • You can check for more recent research on this topic by entering the above article at scholar.google.com, and then click the “Cited by” link to find newer articles that reference this article.
  • I do not know much about cerebral SVD in younger adults; this is not the population that I personally treat nor read much about. (I’m already quite busy trying to keep up with research related to older adults.)
  • As best I can tell, most of what we currently know about health outcomes related to cerebral SVD is based on the studies of older adults. It is not clear to me whether people with cerebral SVD at younger ages should expect similar outcomes. I will not be able to answer most questions related to cerebral SVD in people under age 60.
  • If you are concerned about what caused your MRI findings, or what they might mean for the future, please don’t ask me to tell you, because I don’t have these kinds of answers and I cannot quickly find them online.
    • You should start by talking to your usual doctors, and perhaps a neurologist.
    • If you would like to learn more, consider finding someone specialized in white matter disease in younger adults (e.g. someone doing and publishing research on this topic). Such experts are usually based at an academic medical center. Good luck!
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Comments

  1. Doctor — Tanks a bunch for such rich information.
    I would appreciate it if you can give me your opinion on the following TWO questions:

    1. Due to a recent dizziness issue, I went to Kaiser GA’s urgent care recently who decided to do a number of tests including EKG, Various blood tests, brain/neck CT scan and also an MRI of the brain. All were OK except that it showed an OLD stroke (at least more than last 6 months) AND no recent stroke … hence ruling out the Dizziness cause due to Brain. As I tried to learn more about the strokes on the web, I understand that there can be a Silent stroke & also a Warning stroke but a Silent stroke can lead to brain damage but not a Warning stroke that can perhaps lead to a real stroke later!

    My question is: “Can a Warning stroke also leave a Black mark on the MRI (as there on the left side due to this OLD stroke)”. I have a digital copy of the MRI if required.

    2. I am also told by my Neurologist that I have “small vessel disease” (I am 75 responsible for most daily household finances AND in great health with lots of exercise, Yoga, good food & no smoke/drink habits) and he has advised me to take the NeuroPsycho test to determine the Memory Loss issue even though I do not feel at all that I have a serious Memory Loss issue.

    My question is: “Should I take this extensive 6-8 hour long test and will it show any Memory Loss Problem if there” … I am now doing the AARP Brain fitness exercises and improving my score every day.

    I ‘m a retired Engineer & worked in IBM/ HP for 40 years. I do take BP medicine and monitor my results regularly via annual Doctor visits and/or Home monitor that shows the systolic BP reading to range between 121 to 139 and low end to be around 66. I do plan to start a BP management plan to further reduce the systolic BP to 120 as advised in your SPRINT article..

    Thanks in advance for any info on above ….

    • For your first question: by “warning stroke”, I assume you’re referring to a transient ischemic attack (TIA). By definition, these don’t cause permanent damage, so I would not expect them to leave any sign of damage on an MRI.

      As for your second question: it’s not clear to me why your neurologist would recommend extensive neuropsych testing at this point. Normally, if a person — or if people close to them — report concerns regarding memory or thinking, the next step would be to a) gather more information from the patient and others, to find out just what kinds of memory/thinking problems have been noted (e.g. the 8 Behaviors to Take Note of if You Think Someone Might Have Alzheimer’s), and then b) perform some briefer office-based cognitive testing, to make a more objective assessement of the person’s cognition at that moment.

      A fast test that we often use in geriatrics is the Mini-Cog, which involves recalling three items and drawing a clock.

      The Mini-Mental State Exam (MMSE) is a more in-depth test that can still be done in primary care, but we don’t use it very much anymore. Instead, I and many of my colleagues use the Montreal Cognitive Assessment Test. This test takes 10-20 minutes, and can be done as part of a primary care or neurology office visit.

      I normally would only consider neuropsych testing if I had already done a MOCA test, and if I thought the additional in-depth evaluation was going to help us sort out a difficult diagnostic challenge.

      You might want to ask your neurologist to explain why you shouldn’t do something like a MOCA test first. In terms of preserving and optimizing brain functions, I share my top suggestions here: How to Promote Brain Health:The Healthy Aging Checklist, Part 1.

      Good luck!

  2. I am 70 years old and suffer with acute rheumatoid arthritis. Over the last few years I have developed neuropathy in my lower legs and feet , also I now have nystagmus which causes me to be a
    bit unsteady walking. My neurologist is uncertain what is causing the problem but thinks it might be the arthritis. I had a brain scan and she found small vessel disease deep in the brain. I wondered what your thoughts might be.

    • Regarding your small vessel disease, it is common in all older adults and could also be caused or worsened by the inflammation associated with rheumatoid arthritis. So it doesn’t seem surprising that they would see it on your scan.

      Now, is the small vessel disease related to your nystagmus and/or unsteadiness in walking? That is harder to say.

      In older adults, unsteadiness while walking is often multi-factorial, meaning it’s being caused by many problems at once. For someone like you, it could be due to neuropathy and also chronic damage to joints from arthritis and also some small vessel disease (esp if it’s in parts of the brain that help coordinate walking). And there could be yet more factors, such as leg weakness or medication side-effects.

      Nystagmus itself is usually more closely related to something going on in the brain or nerves between eyes, brain, and vestibular system (in the inner ear).

      I would recommend asking the neurologist to help you further evaluate the nystagmus, and also unsteady gait. If that clinician is unsure, consider a second opinion.

      You could also ask your rheumatologist to weigh in on how well your rheumatoid arthritis is being controlled, and on whether that condition is likely to be a major contributor to these concerning symptoms. Good luck!

  3. Meant to add to my last comment that I have been having a lot of memory problems…. I mean to the point that it is affecting my daily life. I’m messing up financial things, I’m constantly forgetting words, I’m ordering items multiple times or forgetting things altogether. I forget important appointments even when i look right at them on my calendar because I start to get ready and it slips my mind that I’m getting ready FOR something, so I just hang around the house instead. Ugh.

    • That sounds tough, and potentially concerning. It’s common for some aspects of one’s short-term memory to get a little worse as one ages. However, if it’s getting to the point at which it’s affecting one’s ability to function in one’s life, then there might be something more significant going on.

      If the problems are bothering you and are getting worse, I would recommend getting evaluated. Some medical problems (such as thyroid dysfunction, medication side-effects, and more) can cause or worsen thinking problems. For more on what the evaluation usually includes, see:
      Q&A: How to Diagnose & Treat Mild Cognitive Impairment

      Good luck!

  4. Again—-many thanks for both your insightful response to my questions—-and the very helpful site you maintain for folks like me. I wish you continued success in this worthwhile endeavor.

  5. hi this was my dad’s MRI results.he is 72. can you please explain it a bit to me, and tell me what can we do about it .his doctor is out of town and i am very worried.
    “mild periventricular small vessel ischemic disease in both cerebral hemisphere occiptal white matter is seen”

    • Well, it sounds like the radiologist is seeing signs of mild cerebral small vessel disease. Occipital white matter means the part of the brain in the back of the head. This area is especially known for processing visual information: Occipital lobe.

      Generally, there is nothing urgent to be done about a finding of mild — or even more severe — small vessel disease. As I explain in this article, cerebral small vessel disease is extremely common in older adults, often causes no symptoms, and is generally a sign of one or more processes affecting the health of the brain’s small blood vessels.

      Once your father’s doctor is back in town, you can ask him or her to address any additional concerns or questions you have.

  6. Hi my mom has just been diagnosed with chronic small vessel ischemia disease and is not the drug taking type. She insists on drinking some tea made out of freshly cut spices(Ginger, onion,garlice,etc) and says it makes the head aches milder and she is a workaholic that doesn’t get much sleep. What should I do?

    • Well, first and foremost, it’s always good to review tips on how to talk with older parents. Unless you think she’s really not in her right mind, she gets to decide how she can manage her health, and so if you want to make suggestions, it’s important to be very careful and thoughtful about how you do this. You can try to help and provide her with useful information, but it’s not a good idea to try too too hard to make her change, and you always want to start by putting a lot of time into listening and helping the older person feel understood. I have some more suggestions here:
      4 Things to Do When an Older Person Resists Help

      Otherwise, it would certainly be good for her to get more sleep, and address other lifestyle factors that promote physical health and brain health.

      Her spice teas might be helpful, some research suggests that such spices can reduce inflammation, which plays a role in the blood vessel disease of some people. But dietary interventions alone are probably not enough; people usually need to make as many changes as possible, to see real results.

  7. Hi my Mom has SVD and suffers with very weak legs some days she can barely walk and either later the same day or the next she is a lot beter.She was wondering why that happens and if there is anything she can do. Thanks in advance Janai

    • There are many reasons why an older person may feel weak in the legs sometimes. Honestly, I would not expect SVD in of itself to cause occasional weakness, although anything is possible.

      To sort this out, your mother needs to go see a health professional, and she needs a good evaluation to figure out what might be going on. Usually this would involve the clinician taking a good history (which means asking for more information about when and how the problem happens, and also reviewing her past medical history), and then she should have a good physical examination. It’s also common for laboratory tests to be ordered, as part of an evaluation for weakness. Good luck!

      • Hard to say. Fatigue and lack of drive are very “non-specific” symptoms, they can be caused by all kinds of different problems.

        For that matter, cerebral small vessel disease is also a somewhat non-specific finding, as it can be the result of a variety of different processes or disorders affecting the small blood vessels.

        I don’t think fatigue and lack of drive are particularly associated with cerebral SVD, although it also might depend on just which parts of the brain are being affected.

        For fatigue and lack of drive, you would need to start with a good comprehensive exam, which would include detailed questions to uncover other symptoms and also a good physical examination. Good luck!

  8. I am a male age 85 who recently had an MRI requested by my neurologist incidental to a consultation regarding an ocular migraine issue that seems to be getting worse. The report came back with the following narrative comment: “Scattered areas of T2 prolongation throughout the periventricular and subcortical white matter in keeping with mild chronic small vessel ischemic change.”

    What does the term “T2” refer to? Are there clear criteria that distinguish the three types of SVD change (mild, moderate and severe) from each other? Is all SVD change ischemic? Are the symptoms of ocular migraine in any way connected with SVD?

    Thanks for your help.

    • T2 is a term related to the physics of how an MRI creates an image of the brain and other bodily tissues. As a practicing clinician, I don’t usually pay much attention to whether a scan is T1 or T2, but that’s because I don’t read scans directly, I just read the reports!

      You can learn more about T1 versus T2 here: Magnetic Resonance Imaging (MRI) of the Brain and Spine: Basics

      I am not aware of any particular criteria for determining mild, moderate, and severe, but a radiologist would be better able to answer. My guess is that in regular practice, it’s just a judgment call by the clinician. However, in a research study, I would expect there to be a protocol for grading/evaluating scans.

      I am not very familiar with the different migraine syndromes, so would recommend you direct those questions to your migraine specialist or a neurologist.

      • Thanks so much for your helpful reply.

        I failed to mention that I have been prescribed Klonopin in a very small dose (0.5-1.5 mg). at bedtime to relieve the symptoms of Periodic Limb Movement Disorder. Currently I take 0.5 mg. of Klonopin at bedtime. This practice came out of a sleep study i was in over 20 years ago. The Klonopin has helped me to control the sleep disorder.

        Lately, I have learned that Klonopin is associated with causing dementia as a possible side effect. Would this be the case even in such a small dosage? Could Klonopin intake over an extended period of time have any possible connection to the MRI findings I previously described to you?

        I very much appreciate your help.

        • I would not expect Klonopin to have caused your MRI findings, as I’m not aware of an association between benzodiazepines and small vessel health.

          Benzodiazepines such as clonazepam (brand name Klonopin) have been associated an increased risk of developing dementia. Some experts believe that the benzos might themselves be causing or facilitating neurodegeneration, whereas others believe that it’s not a causative association.
          Association between Benzodiazepine Use and Dementia: A Meta-Analysis

          Whether or not benzos might cause or accelerate cognitive decline, they certainly do diminish brain function in the short term, and they often make Alzheimer’s symptoms worse in the short-term. There is also very good evidence that they increase fall risk. So in geriatrics, we discourage benzodiazepine use because we are often trying to help people think their best, and we are often trying to help them reduce fall risk.

          Your dose of Klonopin is not all that small, given your age. If it is necessary to control your periodic limb movement disorder, then the benefits may outweigh the risks. However you should bear in mind that the risks of this medication go up as one ages, so just because it made sense to start it 20 years ago doesn’t mean it’s the optimal approach now. So you may want to ask your doctors if it’s possible to be on an even smaller dose of benzodiazepine, or otherwise look into other options for managing your sleep disorder.

          I have some information on periodic limb movements here:
          5 Top Causes of Sleep Problems in Seniors, & Proven Ways to Treat Insomnia

          Good luck!

  9. Dear Dr Kernisan,
    Thanks for posting such an informative blog. I am writing to you regarding my mother. She is about 68 years old and have been suffering from psychogenic vomiting. Most of time she used to have vomiting bouts and we have to provide glucose drips to control. This has been going on for several years.
    Also, she was having high blood pressure problem for past year and have been treated for the same.

    In recent past (2-3 months) she started falling down abruptly while walking or standing. So we did her MRI Brain with Angiogram. Here are key summary from the report:
    * Microvascular chronic white matter ischemic changes in the bilateral fronto-parietal region.
    * Old lacunar infarcts in the bilateral corona radiata and centrum semiovale.
    * Changes of diffuse cerebral & cerebellar atrophy.
    * No acute infarct, SOL or bleed is seen.
    * Sinus mucosal disease as described (Mucosal thickening is seen in sphenoidal sinuses)
    * Slight Paucity of sylvian branches of MCA on either side .
    * No other significant abnormality is seen.

    Please help me understand how serious is this. What treatment we need to undergo. I am really worried.

    Thanks. Really appreciate your help.

    • Sorry to hear of your mother’s difficulties.

      I can’t really weigh in on how “serious” her MRI findings are. They are consistent with cerebral small vessel disease, but by themselves, they cannot tell you why she has started falling.

      Falls in most older adults are due to multiple factors, but sometimes there is one particular illness or health problem that is driving most of them (or causing a significant worsening in the problem). I have written a lot of articles on evaluating older adults for falls, you may find those helpful. They can be found here: Preventing Falls in Aging Adults.

      You will need to keep asking her doctors questions, in order to determine how serious her condition is and what is causing her difficulties. Good luck!
      .

  10. I am reading Norman Doidge, “Brain’s Way of Healing” which presents an impressive picture of the problem and treatments that seem to have been effective. You do not mention LED light or Laser treatment. Do you have any information on it? MR

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