The dementias: Diagnosis and management

The dementias: Diagnosis and management

Book Review The Dementias: Diagnosis and Management. Edited by Myron F. Weiner. Washington, D.C., American Psychiatric Press, Inc., 1991 ($59.95), 350...

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Book Review The Dementias: Diagnosis and Management. Edited by Myron F. Weiner. Washington, D.C., American Psychiatric Press, Inc., 1991 ($59.95), 350 pp. This volume is comprised of 12 chapters, with over half of them authored by the editor himself or in association with his colleagues. The focus is on practical clinical issues in the diagnosis and management of demented patients, and represents a useful addition to the literature. There is, however, a patchy quality to the book. After an encouraging foreword by Dr. Robert Butler, the first section of the book directly addresses the clinical diagnosis and management of demented patients. In the opening chapter, an exhaustive list of conditions that may cause dementia is presented, and this is a useful reference guide. There is strong reliance on DSM-III-R criteria for diagnoses throughout the book. This is justified for many diagnoses, but several subtypes of organic disorder as classified in DSM-III-R (e.g., organic anxiety disorder and organic personality disorder) have never been validated. Also, there is little mention of either the NINCDS-ADRDA criteria for the clinical diagnosis of Alzheimer’s disease or the Khatchaturian criteria for pathological verification of this condition, both of which are accepted standards in the field. For the diagnosis of incipient dementia, characteristic clinical features are listed as impaired concentration, impaired recent and remote memory, and loss of the abstract attitude. This is an example of the approach adopted by Dr. Weiner in the first half of the book, where he relies more on his own clinical experience than research findings in the field. Though this approach makes it easier for clinicians, the danger lies in the possibility that many of these assumptions may not be valid. The differential diagnosis of dementia vs depression is discussed, but the criteria presented to make this distinction are overly definitive in a complex area where there are more difficult questions than good answers for the practicing clinician. In addition, a subtype classification, namely, 214 ISSN 0163~8343/92/$5.00

frontal dementia, patchy dementia, and temporoparietal dementia, is presented. The empirical justification for the latter two subtypes is unclear. Impairment of cognitive status is emphasized in making the diagnosis of Alzheimer’s disease, as it should be, but the issue of deficits in functional “Dementia as a Psychocapacity is overlooked. dynamic Process” is the provocative title of the second chapter. The application of ego psychology and psychoanalytic theory appears to be overdone; for example, a 70-year-old man being unable to recognize his wife and calling out for his mother, but still able to recognize his son, is described as a form of emotional regression. Many of the psychodynamic constructs proposed could just as easily be attributed directly to cognitive impairment. Similarly, the presumed impact of psychological forces in the demented elderly who develop depression is overemphasized. Depression occurring during the course of dementia is discussed with reference to catecholamine changes in the locus cerulus and ego psychology, with inadequate attention paid to a large number of studies that have examined the more central issues of diagnosis and treatment. Also, involvement of specific brain regions as possible etiological factors for symptoms of depression, anxiety, and psychosis in dementia is ignored. However, the discussion of sleep-wake disturbances is of definite value to clinicians. The chapter on the dementia work-up is one of the better ones in the book. There is an extensive discussion of the utility of SPECT imaging in making the diagnosis, an area related closely to the authors’ research interests. Possible etiologies in the differential diagnosis are listed in detail, but common difficulties encountered in making a diagnosis are not sufficiently emphasized. The reader might have benefited from a brief presentation of problem cases, both in terms of initial evaluation and follow-up. Dr. Weiner’s chapter on the dayto-day management of the demented patient is described in simple fashion, and the clinician will find it beneficial in advising patients and their families. General Hqifd Psychiatry 14, 214-215, 1992 0 1992 Elsevier Science Publishing Co., Inc. 655 Avenue of the Americas, New York, NY 10010

Book Review

Although Drs. Weiner, Debus, and Goodkin provide a number of suggestions on the pharmacological management and treatment of secondary symptoms in dementia, several contentions are not consistent with the existing research literature. For example, the authors suggest that symptoms typical of psychotic depression occur frequently in dementia: “common delusions include that the patient is being persecuted for past misdeeds, that he or she is about to be prosecuted or executed, or that the world has been destroyed.” In fact, several recent studies involving large numbers of demented patients, particularly those with Alzheimer’s disease, have established that guilty and nihilistic delusions are virtually never seen and that persecutory delusions are rarely well formed in demented patients [l]. Available data on the prevalence of delusions, hallucinations, and other behavioral disturbances in dementia are largely ignored. Also, the guidelines for prescribing antidepressants, antipsychotics, or electroconvulsive therapy imply a degree of certainty that is belied by the lack of validation in the existing literature. The second half of the book covers a diverse range of topics, all of which have direct or indirect impact on the clinical management of demented patients. Dr. Ronald Paulman and Dr. William MacInnes have written a concise chapter on the indications for neuropsychological testing in making the diagnosis. Details of what the testing involves and what one can hope to find out from a neuropsychological testing report are sketched out rather than described in detail, and the reader will need to look elsewhere to find out more about the neuropsychological testing process and, its validity in the diagnosis of dementia. There are several well-written sections on practical matters, such as

dealing with family caregivers, legal and ethical aspects of dementia, mobilizing community resources, and structuring environments for dementia patients. The authors of these various chapters have provided thoughtful guidelines for the physician and other clinicians, and draw heavily on their own clinical experience in this regard. The chapter by Dr. Robert Stern and Dr. Kenneth Davis on treatment approaches is excellent, as might be expected from leading researchers with established expertise in the conduct of clinical trials in Alzheimer’s disease. The scales most commonly used in the evaluation of dementia are laid out after the final chapter, and this is a valuable reference. Overall, the book attempts to cover all clinical aspects related to the diagnosis and management of dementia. The unevenness of the book is dramatized by the fact that the chapters on legal, ethical, community, and environmental issues are better than those directly pertaining to the clinical diagnosis and management of dementia. The sustained clinical focus that is maintained throughout the book, however, drives home an important message: we may not have any effective treatments for the most common forms of dementia, but palliative interventions are available and clinicians need to be knowledgeable about a variety of problems faced by demented patients and their families. D.P. Devanand, M.D. New York, New York

References 1. Burns A, Jacoby R, Levy R: Psychiatric phenomena in Alzheimer’s disease: disorders of thought content. Br J Psychiatry 157:72-76, 1990