Brain, Vol. 122, No. 6, 1202-1204,
June 1999
© 1999 Oxford University Press
Book Reviews |
THE DEMENTIAS.
.
Frenchay Hospital, Bristol, UK
This is a recent addition to the `Blue Books of Practical Neurology' series, and, like its sister volumes, is intended for physicians who have to manage people with neurological disorders in the context of their normal daily routine. Although I suspect that the majority of the target audience is probably neurologists, whether trained or in training, the series is clearly also meant to help colleagues in related disciplines, and in this case I imagine specifically psychiatry, geriatrics and internal medicine. The subject matter clearly fulfils the selection criteria used by the series editors, namely that the subject of each monograph has to be an area of medicine in which there has been a significant advance in knowledge, and also that such advances have been, or are being, translated into new ways of managing patients. There can be very few areas of medicine that fulfil these principles more than the field of dementia.
This volume has two separate forewords, whose authors are equally eminent in the field, and have been so for long enough to be able to appreciate the historical development of our increase in understanding of these illnesses. Robert Katzman makes a statement which in itself almost justifies the writing of this book, when he reminds us that in 1966 there were only 10 articles published on Alzheimer's disease noted in Medline, rising to only 52 in 1976, 826 in 1986, but an astonishing 2277 in 1996. Sir Martin Roth provides a more in-depth historical account, which again demonstrates the way in which scientific endeavour is highlighting potential therapeutic targets, not just for symptomatic relief, but also to attack more fundamentally the basic underlying molecular pathology. This explosion of knowledge emphasizes the potential importance of a book such as this as an aid to the non-specialist who needs to keep up to date with the march of progress, without having to sift through a seemingly endless number of papers each year, and who also needs advice about how best to incorporate our increased understanding into daily practice. Does this book fulfil its objectives in this way?
The book is arranged in four parts, three of which have a helpful introduction written by the editors, Martin Rossor and John Growdon. Part I describes the degenerative diseases that cause dementia, Part II scientific advances in understanding the dementias, Part III is a short two-chapter section discussing treatment of the dementias, and is the part that does not have its own introduction, and Part IV is an interesting section on questions and controversies.
It does seem strange to open a book such as this and not find a chapter on Alzheimer's disease, which one might expect to come across in Part I. The editors point out, in their introduction to this section of the book, that its absence is a reflection of the fact that there have been so many advances in Alzheimer's disease that they are covered in considerable detail elsewhere in the other sections. As one reads through the book it is quite clear that this was a sensible and helpful decision, as the breadth of material involved would have been far too great to try and bring together in a single chapter. It also allows the chapters about the other degenerative diseases not to be dominated by Alzheimer's disease. Part I thus has separate chapters on Pick's disease, frontal and frontotemporal dementia, dementia with Lewy bodies, parkinsonian syndromes associated with dementia, and the etiology and clinical features of human prion diseases.
The chapter on Pick's disease starts with an historical review and then moves on to describe the clinical aspects of the disorder and its neuropathology. There is an abundance of illustrations, which are well and clearly presented. All in all, this is a useful review of the current state of knowledge, and my only slight reservation is that there is perhaps more on the neuropathological side than many readers would need, and it might have been helpful to have had a summary for those readers who would have preferred a shorter account.
The next chapter, on frontal and frontotemporal dementia, is a concise and succinct approach to a very confusing group of conditions. It is clearly and logically set out, and provides thoughtful guidance in relation to diagnosis. This is followed by the chapter on dementia with Lewy bodies, which includes a useful section on treatment of the behavioural and neuropsychiatric disturbances that are so often a problem for families and other carers, as well as mentioning the increasing impression that the cholinesterase inhibitors developed for Alzheimer's disease may also one day be proven to be of benefit in this type of dementia. The need to avoid phenothiazines and related drugs could perhaps have been more emphasized.
Following on from dementia with Lewy bodies is the chapter describing parkinsonian syndromes associated with dementia. Although, understandably, more than half of this chapter is devoted to dementia in idiopathic Parkinson's disease, the other important conditions that cause this combination are also covered. These are difficult conditions to separate, especially in the early stages, and particularly for non-neurologists, and there is a very useful table that goes some way to addressing this issue.
The final chapter in this section takes us into the rapidly moving and increasingly confusing area of human prion diseases. Although clearly written, and providing useful clinical information, the eight pages listing specific mutations are probably of most value to the more specialist reader. The clinical overlap and variability inherent within this group of disorders makes it unlikely that the average reader is going to be able to relate specific syndromes to his/her patient.
The first part occupies approximately 150 pages, after which the book moves on to Part II dealing with scientific advances in understanding the dementias. This covers three major areas of investigation that have, in the words of the editors in their introduction, `transformed research into dementia: molecular genetics, neuro-imaging and molecular pathology'. The truth of this is amply demonstrated by the majority of chapters that follow, ranging from the increasingly familiar molecular genetics of Alzheimer's disease, including apolipoprotein E particularly, which merits a chapter of its own, to the less familiar, but equally important, understanding of the molecular pathology of cytoskeletal abnormalities, on the one hand, and bioenergetics, excitotoxicity and oxidative injury on the other. Taken as a group, these chapters are clearly written and well illustrated. The reader's level of knowledge is rarely taken for granted, and there is even a helpful explanation of the use of LOD scores. Important clinical perspectives are not forgotten, e.g. the practical and ethical difficulties involved in using APOE genotyping for predictive purposes.
The chapter on anatomical imaging is well written, but sadly let down by some of its illustrations. These would have been more helpful if enlarged to a size similar to the pathological illustrations elsewhere. This would have allowed a system of arrowhead marking, or something similar, to highlight some of the more subtle changes. The functional neuroimaging chapter is also let down by its illustrations. This is an aspect of diagnosis that is perhaps less familiar to non-neurological specialists and, although colour may not have been a practical possibility, an increase in size of the illustrations would have allowed the greater use of pointers. I also felt that tables listing all PET studies involving Alzheimer's disease patients between 1980 and 1997, and the similar one summarizing the SPECT studies, were perhaps unnecessary. This space would have been better used for illustrations.
The chapters on the role of amyloid, on the one hand, and that discussing the neuronal cytoskeletal abnormalities, on the other, are particularly relevant to Alzheimer's disease, and the relevance of our understanding of these phenomena is discussed in a way that is appropriate, e.g. in relation to the development of diagnostic markers and therapeutic strategies. The relevance of tau to a number of different neurodegenerative diseases is also briefly discussed.
The final chapter in this section, on bioenergetics, excitotoxicity and oxidative injury provides a very helpful and succinct overview of the science of each of these phenomena, and then reviews the evidence for their involvement in a number of different neurodegenerative disorders that cause dementia. This is a helpful starting point for what is probably going to become a rapidly expanding area.
Part III includes two chapters about the treatment of the dementias. The first of these is a fairly straightforward factual account of different approaches, and the drugs that have been developed in relation to these. Most readers will be aware of the cholinergic strategies, although only Donepezil is covered in detail. This chapter, however, provides a useful summary of other non-cholinergic approaches to treating Alzheimer's disease, both symptomatic and also those that may be disease modifying. The authors wisely leave strategies directed at the more fundamental underlying pathology, i.e. amyloid and neurofibrillary tangle formation, to the authors of the relevant chapters elsewhere in the book. This chapter does, however, include discussion of the treatment of non-cognitive features of dementia, and specifically also mentions therapeutic aspects of both vascular dementia and dementia with Lewy bodies. The second chapter in this part of the book is less pragmatic in its approach, at least as far as the clinician is concerned. It blends together epidemiology, history and an overview of the wide spectrum of therapeutic approaches that are being explored. There is a glimpse into the future pattern of drug development, and an intriguing account of the changing pharmaceutical research environment.
Most people reading this book will probably dip into it, and concentrate on specific chapters, when stimulated to do so by a specific p or line of interest. All should, however, read the final three chapters in Part IV. We are all going to have to re-think vascular dementia, and indeed many people are already so doing. The reasons for this are explored in a stimulating chapter on this topic. The age-old question as to whether Alzheimer's disease is just old age is revisited in the second chapter, with a conclusion that is left surprisingly open even in this day and age, stimulating the reader to think further for himself or herself. Finally, the last chapter addresses the controversies in the classification of focal lobar atrophies. Although some of this repeats the substance of earlier chapters, it provides the basis for a discussion as to whether such conditions are, in reality, entities in their own right. These chapters are very helpful in putting the content of some of the earlier chapters into an appropriate context.
In summary, this is quite a lengthy tome, of over 400 pages, that covers its subject matter most comprehensively. Does it fulfil the objectives of the series editors? The answer has to be `Yes', despite the fact that some of the more basic science-based chapters are already a little out of date. Many people working on a regular basis with patients who have dementia will find this book extremely useful, not for reading from cover to cover, but for consulting at appropriate times. The knowledge contained within it is adequate to address common clinical questions and provide an understanding at an appropriate depth of the recent advances that support such conclusions. Many will wish to have their own copy, and it should certainly be available in the libraries of all institutions where those who regularly see patients with dementia work.
Notes
Edited by John H. Growdon and Martin N. Rossor.
1998. Pp 480. Oxford: Butterworth Heinemann.
Price £70. ISBN 0-7506-9920-5. 
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