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September 11, 2012

CHAPTER 7: Ethical and clinically humane end-of-life care for those living with dementia
by Michael Gordon

 

Editors:
Serge Gauthier, McGill University, Montreal, Quebec, Canada
Pedro Rosa-Neto, McGill University, Montreal, Quebec, Canada
Publisher: Future Medicine
Reviewed by: Michael Gordon, MD, MSc, FRCPC, FACP, FRCPEdin

It is always a pleasure to be able to discuss a new book to a receptive audience when I believe the book has something special to offer. When it comes to reviewing books outside the realm of medicine or the medical sciences, reviews often are reflective of the personal and aesthetic views of the reviewer. There are many books written for professional readers on the fringe of medical science that deal with non-clinical aspects of medicine and many that have translated important medical concepts to the lay audience and others in the form of memoirs and novels of the personal and historical type that add a great deal to the general wealth and richness of medicine and the associated medical sciences.

To undertake an academic text book is always a daunting task. Generally if experts and specialists in the field cannot write such a book without the help of others and currently the idea of editors securing experts to write the relevant chapters is a well-accepted methodology for achieving that goal. That being said it becomes the responsibility of the editors to make sure that those that they recruit to write the relevant chapters have the academically sound and clinically and research-based capability of doing so and on top of that have the writing skills to achieve their goal. Moreover, for the chapters to hang together in one strives to have some degree of congruence in the writing approaches and styles, while at the same time promoting the particular capabilities of the writers of each chapter. At the end it is hoped that the chapters hang together into a whole that attracts the reader and provides a perspective on the subject and each of its varied components that would be hard to achieve if the reader decided to explore each of the subject chapters separately without the benefit of them being collated, edited and reference into one easily accessible book.

I am therefore pleased and honoured to not only present the book to subscribers of HealthPlexus.net, Advances in Alzheimer’s Disease Management edited by Serge Gauthier and Pedro Rosa-Neto but to have been one of the contributors. At a time when the knowledge surrounding Alzheimer’s disease and other dementias is on the one hand expanding rapidly from the scientific perspective, for the practicing physician and patient living with dementia and their families, the challenges seems to be overwhelming. There seems to be a huge disconnect between the understanding and scientific progress of the causes in many domains of enquiry and the actual clinical impact that all this new knowledge currently has that physicians in the front lines of care can utilize clinically.

In medicine however, one never knows what key will be the one that opens the door we are all looking to enter. At any given time all we can do is to try and figure out using the best clues and evidence available to know what secrets lay behind that door. The readily accessible E-book format in which Advances in Alzheimer’s disease management is produced allows for a relatively low cost alternative to the usual costs of hard copy texts. The content of the book covers all the main challenging concepts and recommended or best-practices as they exists currently. Obviously in time, perhaps a very short time, some of these will change but for those in the field we all know that many of the concepts and practices have not changed in many years.

The table of contents includes the following subjects by the authors listed next to the chapter titles, with mine at the end. I have been given permission to reproduce my chapter, Ethical and clinically humane end-of-life care for those living with dementia on the HealthPlexus.net website so that subscribers can get a taste of the e-book itself.

1) Genetics of Alzheimer’s disease by Jayashree Viswanathan, Hilkka Soininen & Mikko Hiltunen;
2) Diagnosis of Alzheimer’s disease by Pedro Rosa-Neto, Jared Rowley, Antoine Leuzy, Sara Mohades, Monica Shin, Marina T Dauar and Serge Gauthier
3) Available symptomatic antidementia drugs by Marie-Pierre Thibodeau and Fadi Massoud
4) New drugs under development for Alzheimer’s disease by Lezanne Ooi, Kirubakaran Shanmugam, Mili Patel, Rachel Debono and Gerald Münch
5) Management of agitation and aggression: controversies and possible solutions by Clive Ballard and Anne Corbett
6) Guidelines for the diagnosis and treatment of Alzheimer’s disease by Serge Gauthier and Christopher JS Patterson
7) Ethical and clinically humane end-of-life care for those living with dementia by Michael Gordon

For those interested in ordering the book, this can be done through the following links:
The direct URL for the book is:
http://www.futuremedicine.com/doi/book/10.2217/9781780840840

For those who are interested in finding more information about the book/our e-book series, the email address is:
info@futuremedicine.com
For those who wish to place an order, the email is:
sales@futuremedicine.com

November 8, 2011

by Michael Gordon, MD, MSc, FRCPC, FACP, FRCPEdin
with Natalie Baker, BA, MSc
Publisher: iUniverse Publishing
Reviewed by: D’Arcy Little, MD, CCFP, FRCPC

Modern medicine may offer seemingly promising treatments, but eventually, the impact of Alzheimer's disease and other ailments of dementia can cause profound deterioration in the patient's quality of life. The focus must eventually shift to compassionate end-of-life care.

Michael Gordon in his new book “Late-Stage Dementia: Promoting Comfort, Compassion, and Care” shares his extensive experience with health care professionals and families struggling with these poignant and difficult decisions.

If you are a health care professional who is responsible for caring for frail elders and agrees with the sentiment: “I want to provide the best care possible” or you are a family member of a patient with later stages of dementia and trying to ensure the most compassionate care for your loved one and struggle with painful decisions when confronting the inevitable while providing love, compassion and care, you may want to source this book. It is available online at Amazon.ca and Chapters.

And here you may read and watch what Dr. Gordon says about his latest book himself:  Dealing with difficult choices in end-stage dementia

by Michael Gordon, MD, MSc, FRCPC, FACP, FRCPEdin
with Natalie Baker, BA, MSc
Publisher: iUniverse Publishing
Reviewed by: D’Arcy Little, MD, CCFP, FRCPC

September 1, 2006

Jeffrey Farber, MD, Brookdale Department of Geriatrics and Adult Development Mount Sinai School of Medicine, New York, NY, USA.

An educational video entitled “Compassionate Care in the ICU,” funded by Ortho Biotech and produced by the Society of Critical Care Medicine, aims to improve end-of-life care for patients dying in the intensive care unit (ICU). It is a well-paced, well-filmed video that alternates between advice and opinions from experts in the field of critical care, and poignant, still, black-and-white and colour photographs of common scenes in the ICU. There are two distinct videos: a shorter version intended for professional use, and a second for families of patients being cared for in the ICU. While overlapping in core content, there are significant differences between the two.

The professional video begins with recognition by experts that good communication is both lacking and needed in the ICU. Common barriers to effective communication are discussed, such as deficiencies in the physical environment, physician-family misunderstandings and conflicts, and the paucity of formal staff training in communication skills. Specific examples, such as noise, bright light, and a busy and fast-paced environment are noted, but advice on how to deal with these impediments is lacking. While the video stresses the importance of listening, of “putting down your stethoscope” and “being with a dying patient,” it does not sufficiently address how to establish goals of care with a patient’s family. Indeed, the term “goals of care” is not introduced until the very end of the 25-minute video.

The professional video does a nice job of discussing the need to guide families through the transition from the aggressive, curative approach of a critically ill patient to the symptom-focussed, palliative care approach. It clearly highlights the importance of treating the patient-family unit and credits the physician’s role in providing good palliative care. A highlight of the video features an ICU physician clearly explaining the necessary skills involved in organizing and carrying out an effective family meeting, from preparation to finding a quiet setting, to having a focussed agenda and summarizing and establishing a clear follow-up plan for the family. This is followed by another expert’s recommendation to have physicians train to communicate via professional actors playing family member roles.

While the video makes a convincing argument for the need to better care for dying patients in the ICU, it unfortunately fails to touch upon common specific scenarios that would help its intended audience. Shifting from a curative to a palliative approach often occurs in stages over time. The best tool to help this transition along is a clear and frank discussion of the goals of care. When it becomes clear that the goal is comfort, then the plan of care needs to be reviewed and revised so that all interventions and therapies accord with this goal of care. It is common for clinicians and families to decide together for example that no further blood draws or diagnostic radiographic imaging be performed. Likewise, commonplace, almost standard, ICU monitoring such as telemetry, urinary catheters, and continuous intra-arterial blood pressure need to be reviewed and discontinued if not achieving the goals of care. Unfortunately, there is not one photo in the video of an ICU patient that is not connected to a telemetry monitor and various intravenous catheters.

Likewise, the option of having dying patients transferred out of the ICU to a more appropriate setting is not mentioned. As one clinician described in the video, ICU care is best considered a “therapeutic trial” of a clinical strategy. When this trial fails, then one valid option is to transfer the patient out of the ICU setting to an environment where the goals of care can be better achieved. The ICU is indeed a busy and fast-paced environment with an invasive and aggressive approach to curative care, and it is not feasible to expect the professionals working there to easily shift gears and embrace and excel in providing expert palliative care. While it is important for intensivists to acknowledge the importance of palliative care and good communication skills, it is also important to recognize that optimal end-of-life care more often and readily occurs outside of the ICU setting.

While the expert opinions and still photos are effective, what’s missing in this professional version of the video are the personal and the patient-family unit’s voice. There is no physician account of a specific memorable case, nor a deceased patient’s loved one discussing her experience with end-of-life care in the ICU. This stands in sharp contradistinction to the more touching and personal family version of the video.

In the family version of the video, similar issues such as good communication and the importance of effective symptom management are well-addressed. In addition, establishing goals of care through ongoing communication over time is much better emphasized. There is a wonderfully moving account by a critical care physician of a previously healthy patient who became quadriplegic and ventilator-dependent after a motor vehicle accident. He expertly describes the patient’s eventual transition to palliative care, removal of mechanical ventilatory support, and dying with his family present, drinking a glass of red wine, and being kept free from dyspnea with the appropriate administration of morphine. There is a similarly well-done piece discussing the importance of advanced care planning, specifically highlighting the need to designate a health care proxy and to discuss with the proxy what is an acceptable functional state and quality of life.

The family version does a much better job of clearly stating that there is always something we as professionals can do for patients, that withholding life support does not equal withholding care, and that technologies can be correctly described as death-prolonging as opposed to life-extending when used inappropriately. Families are encouraged to initiate conversations with critical care staff and are assured that dying does not have to be painful nor isolating. There is an effective scene of a critical care expert advising family members on how to achieve closure with a dying loved one. She specifically addresses forgiving the dying person, asking for forgiveness, saying, “I love you,” and then saying goodbye. Likewise, there is a powerful still black-and-white photograph of a patient in the ICU sitting up in a chair with a neck dressing covering what is likely a recently discontinued central venous catheter, shaking hands with a physician. This photo masterfully shows the potential of the ICU to be a place where a person can die a good death. Nearly all that is lacking in the professional version exists in the family version. I would advise critical care units to use both versions to help educate staff to improve care for dying patients and their loved ones.

Jeffrey Farber, MD, Brookdale Department of Geriatrics and Adult Development Mount Sinai School of Medicine, New York, NY, USA.

August 1, 2006



Editor-in-Chief: Ilkka Kunnamo
Publisher: Duodecim Medical Publications (March 2005)
Reviewer: Meteb Al-Foheidi, Medical Resident, University of Toronto


When I was originally asked to review this book, I anticipated examining a pocket-sized guide, but I was surprised to receive a textbook-sized volume running1,311 pages.

When I started to review this book, I tried to cover some topics that I knew and others that I had little knowledge about. At the time I delved in I was doing my emergency medicine rotation, where I was exposed to a wide variety of surgical and medical emergencies in an urban academic hospital. I planned to check every case that I encountered in the Emergency Room with the information contained in the book. For instance, I had an allergic rhinitis case, and I went looking for this in the book. In this and other cases, the text proved to be a good resource: the material was informative and clear, and it provided me with the ARIA guidelines and classifications.

The guide is further enhanced by its thorough forward, preface, and list of abbreviations. It also features good-quality cover design and material.
However, readers should be aware of a few flaws. First, I noted several spelling mistakes (for example, the word “Pheo” was written as “feo”). Second, main chapters were not categorized properly for easy searching. Generally, each chapter dealt with a specialty (e.g., cardiology or pediatrics). But there were some chapters that should have been subchapters within specific specialties: diabetes should fall under endocrinology and birth control under obstetrics and gynecology. While they were likely allotted their own chapters because they are extensively studied conditions or categories, I found it poor on the level of organization.

Furthermore, sections under chapters were improperly categorized. This may cause confusion or even make it difficult to find the information easily without going through all of the contents’ subsections. For instance, page 89 featured material about Hospital Investigations. The first point referred readers to a page still further ahead, page 100, which was about “Secondary Hypertension.” Sending readers back and forth to read about one subject should be avoided.
Other examples of poor organization included chapter content. Some chapters were diseases and others were symptoms. For example, Pulmonary Diseases started with Hemoptysis. Etiologies such as infections, tumours, cardiovascular disease, trauma, etc., were discussed. Then under Differential Diagnosis, the authors addressed the importance of the patient’s history, clinical examinations, and chest x-ray, which are essential for differential diagnosis. As another example of disorganization, the writers opted to explore specific diseases of the respiratory system within a chapter dealing with a symptom.

Some chapters were not evidence-based such as Occupational Health and Pollution—a concern in a text devoted to evidence-based guidelines.
Regarding references: the textbook mentioned only grading references, but no tables or summary and references were listed at the end of each section. In my opinion, this kind of book should contain tables, easy-to-follow flow charts, and summaries that are specific to that section.

The book should have been devoted to guidelines only, based on the title, but the authors/editors went beyond that and added information that one would only find in general medical textbooks and reference guides, such as adding detailed definitions, epidemiology, clinical presentations, and investigations that lacked connection to either guidelines or to evidence-based medicine. Thus the book deviates from its title and is a hybrid of evidence-based guidelines and a standard textbook.

My overall assessment of this book: I believe it will be helpful for the generalists for whom this book was intended. As for me, I will keep this copy on my shelf and I will use it for topics outside my specialty, internal medicine. It will be more useful as a general reference for me in other areas such as surgery, pediatrics, and so forth.



Editor-in-Chief: Ilkka Kunnamo
Publisher: Duodecim Medical Publications (March 2005)
Reviewer: Meteb Al-Foheidi, Medical Resident, University of Toronto


When I was originally asked to review this book, I anticipated examining a pocket-sized guide, but I was surprised to receive a textbook-sized volume running1,311 pages.

April 1, 2006


Authors: Ernest Rosenbaum, MD, Isadora Rosenbaum, MA
Publisher: Andrews McMeel (September 1, 2005)

Reviewer: Lesley McKarney, PhD, Editorial Director, Geriatrics & Aging

A diagnosis of cancer brings with it many questions and a need for clear, understandable answers for both patients and their families. There is a multitude of information about cancer available at bookstores, on the Internet, and on television. It can be overwhelming and insufficient because not all the answers are available--from anywhere--and when they are available, they are not always accurate.

Author Ernest Rosenbaum, MD, FACP, a clinical professor of medicine at the University of California, San Francisco, is himself a survivor of esophageal cancer. Together with his wife Isadora and almost 80 medical advisors and contributing authors, all of whom serve as top specialists in their respective fields of cancer treatment and research, the Rosenbaums have assembled Everyone’s Guide to Cancer Supportive Care, a comprehensive assimilation of information relative to the disease of cancer written for patients and caregivers. It includes accurate but palatable descriptions of physiological changes and methods of psychological coping, and encourages patients to be more involved in their care. As correctly observed in the preface by Dr. I. Craig Hendersen, “…our modern medical system allows too little time for the doctor to provide everything the patient needs to live with and overcome this disease.”

The book serves as a companion read to Everyone’s Guide to Cancer Therapy: How Cancer Is Diagnosed, Treated, and Managed Day to Day. While the latter deals with issues surrounding the diagnosis and treatment of cancer, Cancer Supportive Care is designed to guide patients towards an organized program of comprehensive rehabilitation by examining psychosocial aspects (e.g., loneliness and stress), nutrition, exercise, sexuality, nursing, hospital issues, community services, medical economics, and end-of-life care.

A hefty reference running at 468 pages, Everyone’s Guide to Cancer Supportive Care is divided into six sections. The first section attends to what typically happens when a patient first learns about the diagnosis and what treatments are available, as well as treatment side effects and options for pain control. There are helpful chapters describing surgery, radiation therapy, bone marrow transplantation, chemotherapy, alternative and complementary therapies, and clinical trials, though the lengthy description of targeted therapy of cancer is far too advanced for the layperson. The two chapters on side effects of cancer therapy include information on the consequences of such (e.g., severe neutropenia, for example, can lead to delays in or termination of chemotherapy), advice on how the patient and/or doctor can reduce the impact of side effects, and what is tolerable. The chapter on pain control attempts to dispel the myths surrounding opioid use.

The second section coaches patients on regaining control of their confidence and self-esteem. Titled “The Role of the Mind,” it discusses coping strategies for stress and depression--natural responses to news that a person has cancer--and whether or not a patient’s attitude has an impact on medical outcome. In particular, this section has chapters discussing the value of religion, spirituality, and creative expression in helping patients confront and deal with their illness.
Perhaps the most valuable section of the book for the patient, section three focuses on the care of the body. In addition to emphasizing the importance of a well-nourished patient and achieving a balanced diet, this section also instructs on nutrition for symptom management and control, particularly as it relates to the type of treatment or cancer. Which foods least irritate the bowels of patients who have undergone a colonectomy or colostomy? How do you bypass the problem of difficulty swallowing, mucositis, and dry mouth in head and neck cancer cases? What can be done for loss of appetite due to chemotherapy or morphine-induced constipation? And so on. These are also dealt with to some extent in the chapters on modified diets, recipes for the chemotherapy patient, multivitamins, and complementary medications. Rehabilitation and fitness exercises (with illustrations), insomnia, and sexuality are also covered.

Section four includes supportive and social services for life and death issues, such as in-hospital routines, in-home support groups, home nursing, hospice care, grief, and recovery. Section five covers the sensitive topics of when to consider an advance directive, preparing a will, and arranging a funeral or memorial service. The last chapter, “Choosing Life,” reinforces the major messages throughout the book and reminds patients of the relevance of their will to live and the interaction of body, mind, and health.

Finally, the book finishes with a list of supportive care resources including Internet resources, support groups, and relevant literature.

This is an impressive resource for all those wanting to learn about cancer and its consequences. In truth, I have only one criticism to make of this book: the reference in the title to it being Everyone’s Guide is somewhat misleading. The book requires (or assumes) postsecondary education of its readers, or at least grade 10 comprehension--an all too common mistake made in medical literature. A physician would be wise to consider the patient’s and family’s abilities to read and understand the content before recommending such a detailed and possibly intimidating book.

Despite this, physicians and other health care providers will certainly appreciate this comprehensive and well-written overview of cancer supportive care as a teaching tool, and it is a valuable addition to the library of any cancer clinic.


Authors: Ernest Rosenbaum, MD, Isadora Rosenbaum, MA
Publisher: Andrews McMeel (September 1, 2005)

Reviewer: Lesley McKarney, PhD, Editorial Director, Geriatrics & Aging

February 1, 2006


Editors: Wilbert S. Aronow, Jerome L. Fleg, Eds.
Publisher: Marcel Dekker, Inc., 2003

Reviewed by: Jagdish Butany, MBBS, MS, FRCPC, Consultant Cardiovascular Pathologist/Director Autopsy Services; Co-Editor-in-Chief, Cardiovascular Pathology; Professor, University of Toronto; Director, Division of Pathology, Department of Laboratory Medicine and Pathobiology, Toronto General Hospital, Toronto, ON.

This third edition of Cardiovascular Disease in the Elderly reflects well and in detail the age-related changes in cardiovascular disease, as well as its presentation, diagnosis, and management. Cardiovascular disease represents an increasing and important cause of morbidity and mortality in middle and even more so in old age, accounting for nearly half (if not more) of all adult deaths. The chapter subjects in this book reflect the wide spectrum of the aspects of cardiovascular disease that the individuals who deal with cardiovascular disease in older adults need to be familiar with. The topics are well chosen and the authors of each chapter offer good details regarding them.

The materials covering the cardiovascular system are well divided into numerous sections, each of which appears to be well addressed and covered. Many of the sections are significant in detail, something that should serve as a good resource for anyone dealing with cardiovascular disease in older adults. It is difficult to imagine anyone who, given the changing demographics in countries, will not have to deal with them in some stage or another.

Some chapters are of particular interest, as they are not often covered well in any books. Amongst these are the chapters on peripheral vascular disease in older adults. Given the significance of peripheral vascular disease in this patient group, the introduction to the condition, discussion of the causes, and then the detailed discussion of abdominal aortic aneurysms, thoracic abdominal aneurysm, mesenteric ischemia, and renovascular disease are well done. The discussion of smaller vessels, that is, lower extremity arterial disease, is slightly less detailed.

The section on medical management of peripheral vascular disease and the discussion of reconstruction gives good insight into the options available. The discussion of the need for amputations in people with peripheral arterial disease is appropriate and should give the reader current information with regard to options, even though amputation may be considered a last resort. The discussion of percutaneous transluminal angioplasty is good, though given the rapidly changing nature of materials of which stents are made and designed it may already be slightly dated.

Each section appears to have a good number of references, which should be of help to the individuals interested in more detailed information.
The section on the pathophysiology of coronary artery disease, that is, the basis of the understanding and management of coronary artery disease, is written by experts in the field and is well done. The slightly surprising feature is the good deal of detail offered so that even a rapid review of this chapter would help the reader understand the basis of its genesis and management.

Very appropriate for a book of this kind dealing with patients of this age group is the final chapter on “Ethical Decisions and the Quality of Life in Older Patients with Cardiovascular Disease.” This section is dealt with well and appropriately and since, as the authors begin this section with, “Death is the only certainty in life,” it is essential that anyone dealing with older adult patients be conversant with it. Some of the comments in this section are very appropriate and ones that many physicians need to take to heart (no pun intended). The section also discusses Do Not Resuscitate orders and offers a brief update on euthanasia and the “Oregon Death with Dignity Act.” In short, this book provides a good and detailed overview of the genesis, investigation, and diagnosis of cardiovascular disease in older adults. It provides a very welcome edition (an updated version of the previous edition) for every practicing physician who deals with older adults.


Editors: Wilbert S. Aronow, Jerome L. Fleg, Eds.
Publisher: Marcel Dekker, Inc., 2003

Reviewed by: Jagdish Butany, MBBS, MS, FRCPC, Consultant Cardiovascular Pathologist/Director Autopsy Services; Co-Editor-in-Chief, Cardiovascular Pathology; Professor, University of Toronto; Director, Division of Pathology, Department of Laboratory Medicine and Pathobiology, Toronto General Hospital, Toronto, ON.

January 1, 2006


Authors: Bart J. Mindszenthy and Michael Gordon, MD
Publisher: The Dundurn Group, Toronto, ON.

Reviewed by Hazel Sebastian, MSW, RSW, Social Worker, Regional Geriatric Program, Toronto Rehabilitation Institute, Toronto, ON.

Although “Parenting Your Parents” is directed to families, care providers, policy designers, and professionals who assist them can also learn from reading this remarkably moving book. Readers will find significant insight into end-of-life challenges faced by care receivers and providers. Since adult children often feel unprepared for the task of helping their aging parents, they will find the authors’ description and discussions of this daunting task through stories of nineteen Canadian families extremely useful. The authors--Dr. Michael Gordon, a renowned geriatrician, and his coauthor Bart Mindszenthy--reflect on the details of providing care with all of its struggles and rewards, blending their extensive professional and personal family experiences. The second edition includes an expanded personal parenting planner and an updated resource directory for every province in Canada.

The nineteen case studies delve into the everyday life of family caregivers and their parents, their journey of love and pain, and the hope that they have made appropriate decisions along the way. There is plenty of room to make mistakes while venturing into this unfamiliar world of care providing. A close partnership between the family caregivers and health care professionals will prevent premature institutionalization, and increase the longevity of the caregiver and care recipient relationship.

These stories of families are selected from diverse family backgrounds, faiths, and cultures from different provinces of Canada. The end-of-life care concerns and trials they face often test the true strength of the family relationships. These intimate stories describe unpredictable events in their lives and the need for flexible, creative ways to deal with them. They inform the caregivers to pace themselves to go through a journey of caregiving that may last decades; in addition, caregivers will feel that these stories validate their expectations and personal feelings of failures and successes. The book identifies some of the controversies encountered with siblings and health care professionals, and it captures the unanticipated emotions experienced in the huge responsibility of providing daily care.

The caregiving experiences in this book chronicle different paths but they do not claim to cover every family situation. Still, families facing completely different problems can benefit from reading the book and discovering helpful advice in various segments; it may stimulate lateral thinking to address unique issues that confront other families.

The “Healthcare Professional Point of View” presented after each case study offers alternative approaches to resolving crisis points and emphasizes the usefulness of seeking early professional interventions. A delay in seeking professional assistance can unnecessarily increase the stress on parents and care providers. Timely assistance from home health care providers, learning the strategies targeting challenging behaviours, and environmental modifications can contribute to more successful coping. The professionals reading the book may find the richness of the text gently probing the limit of their knowledge and skill level. It will encourage a professional to find creative ways to work around restrictive agency policies and improve his or her repertoire.

The “Personal Parenting Planner” is particularly important for use in care mapping. It creates a cognitive and conceptual space for caregivers to raise questions and resolve problems. It strengthens the planning by focusing on the areas and details not always included. The use of the parenting planner is therapeutic for those who feel overwhelmed by the responsibilities and consumed by caring duties. It brings a sense of control and direction to the whole process.

The updated directory of resources will assist in finding the help needed. It will reduce the time spent to identify services in the community. The list includes a wide range of general resources, services for special needs, driving capability assessments, and home modification. It outlines the procedures to follow to access publicly funded federal and provincial services, and private agencies that can supplement the care. The suggestions for long-term care placement planning assist anyone who is helping the parents, either locally or from a long distance.

The title Parenting Your Parents suggests the role adult children have to assume to assist parents when they become frail. According to the authors of this book it is a common phenomenon around the world, but this book examines the familial and societal issues in Canada. To be successful, it advocates for a balance in all areas of a care provider’s life and careful planning. The help given effectively and lovingly to parents has many similarities to the role of parenting children. There are also important differences. Since the parents enjoy the authority and advantage of many more years of life experience, they will expect to have the final say in all the decisions affecting them or they may delegate. To minimise the role conflict and the parent’s feelings of loss of control, there is a need to respect the boundaries of the parent-child relationship.

The personal experiences of parents depending on their adult children at the end of their life to provide physical and emotional care fill the pages of this extraordinary book. The value of the book is in its creation as a guide for seasoned caregivers who are struggling to cope at times with the responsibilities, and to give practical advice to future caregivers. It’s also an invaluable resource for administrators of long-term care facilities, home care coordinators, and health care professionals. The contributions of this easy-to-read book are a definite addition to the existing information on caring. As a professional working with frail older rehabilitation clients and as a family caregiver for my mother, the book has inspired some new thinking and enabled me to reflect on ways to share the caregiving responsibilities with my siblings. It has also improved the quality of our interactions.


Authors: Bart J. Mindszenthy and Michael Gordon, MD
Publisher: The Dundurn Group, Toronto, ON.

Reviewed by Hazel Sebastian, MSW, RSW, Social Worker, Regional Geriatric Program, Toronto Rehabilitation Institute, Toronto, ON.

April 1, 2005


Author: Jennifer P. Schneider
Publisher: Healthy Living Books

Reviewed by Jackie Gardner-Nix, MD, Chronic Pain Consultant, Pain Management Program, Sunnybrook and Women’s College Health Sciences Centre; Pain Clinic, St. Michael’s Hospital, Toronto, ON.

You know you’ve been given a good book to review when you wish you had written it! Jennifer Schneider serves up a worthy paperback tome on chronic pain that will be valued by many of those suffering pain or living with a family member with pain. Among its virtues is its accessibility--any reader with at least a grade twelve education should have no problem cracking it. At 304 pages in length, readers are more likely to dip into it for selected topics than read it cover to cover, particularly as chronic pain patients tend to have limited attention span and recall. But for that purpose, it is well worth setting on the bookshelf.

Schneider begins the book with an informative introduction intended for those who live with chronic pain, defining pain and the differences between acute and chronic pain, nociceptive and neuropathic pain, and “breakthrough” pain. She describes pain prevalence in the United States and lists the most common types of pain encountered by physicians: back pain, arthritis, migraines, fibromyalgia, and so on. The NMDA receptors and their role in pain are discussed. Schneider also includes a useful lesson for lay readers in how to interpret evidence-based findings, explaining the different types of clinical studies (double blind, placebo-controlled, etc.).

Chapter 2 addresses finding the right health care professional and assumes the existence of an ideal world where you have a choice! She acknowledges that physicians often undertreat pain due to lack of knowledge and understanding of the condition, and many fear sanctions from governing bodies if they prescribe narcotics.

Subsequent chapters deal with non-opioid medications used for pain and cover all the usual adjuvant medications, including a section on the controversial coxibs and topical agents. One chapter on opioid medications makes it clear that the author is not “opio-phobic”--a welcome fact for many patients who need chronic pain management. However, the reader could potentially misinterpret this chapter as espousing that all pain is responsive to painkillers, as Schneider seems to paint a rosier picture of the role of opioids in chronic pain than perhaps they merit. She cites studies that show efficacy of opioids in various types of pain and tends to ascribe tolerance development (reduced analgesic efficacy over time) as being due to worsening of the underlying condition, a view that is long out of date. Tolerance to analgesic efficacy of opioids is not rare! The studies she quotes do not reflect the true clinical picture of the challenges we face in finding stable doses of opioids that can return patients to the work force or to normal functioning. Similarly, there is no discussion of the extent of the reduction of pain scores by medication interventions and how that translates to improving function. Sleep studies that alert those on chronic opioid therapy to the possibility of sleep apnea are addressed. Nevertheless, Schneider is diligent in discussing side effects of opioids such as constipation, nausea, sexual difficulties, and sedation, and she adequately addresses the issue of driving under medication. Moreover, the proceeding chapter appropriately emphasizes the difference between addiction and physical dependency.

To complete the discussion of conventional therapies for chronic pain, a chapter is dedicated to alternative therapies, including acupuncture, yoga, tai chi, massage, prayer, and cognitive behaviour therapy. The chapter spends little time on meditation but more on hypnosis. Jon Kabat Zinn would not appreciate her interpretation of his mindfulness meditation as a “relaxation technique,” but it is difficult to cover such a wide range of topics and be accurate in describing them all.

One of her particular interests is clearly the influence of personality types on chronic pain, and 61 pages are devoted to describing this--a part of the book many lay readers are likely to go to first. But though she discusses how personality traits affect an individual’s capacity to cope with pain and disability, she fails to connect these traits and the initial development of chronic pain. Moreover, she does not acknowledge the literature dealing with pain-prone personalities or the concept of secondary gain.

Schneider concludes by looking at the indirect and direct costs of chronic pain and describes how family and friends can help the patient. A discussion of current research and new developments rounds out the text.

This book is a good resource for health care professionals and educated readers alike. It would be a worthy reference for health care personnel in locales such as long-term care facilities. Jennifer Schneider has attempted a comprehensive guide on chronic pain, a daunting task considering that many books dealing with clinical issues rapidly become out of date. All in all, this is a timely book that ably sums up where things are, right now, in chronic pain.


Author: Jennifer P. Schneider
Publisher: Healthy Living Books

Reviewed by Jackie Gardner-Nix, MD, Chronic Pain Consultant, Pain Management Program, Sunnybrook and Women’s College Health Sciences Centre; Pain Clinic, St. Michael’s Hospital, Toronto, ON.

March 1, 2005


Author: Chris Helopoulos
Publisher: Jones and Bartlett

Reviewed by Paul Arnold, MD, MCFP, Emergency Physician, University Health Network;
Faculty, Faculty of Medicine, University of Toronto, Toronto, ON.

If you were considering purchasing and using a handheld computer for professional use, what would you need to know to make good choices? The Medical Professional’s Guide to Handheld Computing by Chris Helopoulos makes a noble attempt to meet the challenge.
Mr. Helopoulos is a physician assistant and the assistant director of the Barry University Physician Assistant Program. He is a firm adherent of the “less can be more” school of writing. The text is brief, with an accessible writing style that avoids technical jargon. Its chapter structure is well organized by topic. The author encourages you to dip into the book and sample it like a buffet, partaking only of what you need or want. However, it is compact enough to read in an evening. The result is a very effective and enthusiastic primer on Palm™ handheld computing for medical workers. Regrettably, it isn’t made clear until one is well into the second chapter that the author intends to focus solely on Palm™ Personal Digital Assistants (PDAs), excluding Pocket PC devices altogether. This is a pity, as much of the medical software reviewed later in the book is applicable to both platforms, and Pocket PCs are a legitimate choice for health care workers.

With that said, the book addresses the needs of its target audience. Beginners will find solid suggestions and advice to help them choose a handheld. The more sophisticated user will find useful programs and medical references. The author also shares many insightful tips and tricks with a focus on medical users, making the book a useful reference tool.

The text is copiously illustrated with black and white screen shots so that the reader can gain an appreciation of what software is like during use. The illustrations lack descriptive captions but all are numbered and referenced in the text. There is no index of images.
Most of the book is devoted to exploring software. The chapter on the Palm™ built-in applications is thorough but repeats what can already be found in the Palm™ manuals. A broad range of third party programs is described, including utilities that enhance the functionality of Palm™ handheld computers. Beginners and experts alike will certainly find useful ideas and software in these chapters.
The accompanying CD has a wealth of programs, most of which date from 2003 and a few from 2002. Of course, newer versions of many of these programs have been released since the CD was prepared for publication, but the beauty of this compendium is that you can try out many programs without ransacking the Web. Updates are easily located online if a program seems promising. Note that some of the software is limited until a registration fee is paid to the developer (not the author of this book) but this won’t prevent one from thoroughly exploring the functions of most of them.

Time can be cruel to medical computing reference texts. For the most part, the author has wisely avoided detailed coverage of specific models. However, some material in this book is already out of date. For example, the author refers extensively to the defunct Handspring brand. These comments and instructions are not helpful to prospective owners. The book was also prepared before the latest versions of the Palm™ operating system were released. This is important because “hacks,” handy little utility programs that receive well-deserved attention in the book, won’t work on the newest devices.

It is also disappointing that Mr. Helopoulos neglects to mention how important it is to protect data before testing new software, in case things go awry. Backup software is one of the few important categories that aren’t included in the chapter on third party utilities. This is critically important for people who do serious work on their PDAs. There is very little discussion of patient tracking or charting SW, which is not acceptable in a guide for medical professionals. Moreover, there is no consideration of the topic of securing the data on handhelds, a particularly relevant subject in view of HIPAA and equivalent Canadian legislation regarding patient records and privacy.

A few words of caution for Canadian doctors and nurses: no mention is made of reference texts that use Canadian drug names, so the reader is required to look elsewhere for information on these products. Moreover, while the guide contains a modest glossary and an adequate index in the text, there is no index of web addresses (URLs) for the companies and software described in the book. That information is available on the CD but is poorly configured. One has to open Windows Explorer to find instructions on how to get at the software and to access the list of web sites that the author has included. This is an excellent resource but it is too well hidden.

This slim volume has some deficiencies if one is looking for help with data security or patient tracking software, but otherwise is a worthwhile tool for someone contemplating the purchase of a Palm™ handheld within the next year or so. To those interested in other handheld computer systems, this book will provide only some hints of what is possible, not what is actually available, for Pocket PC, Linux, or RIM Blackberry. Nonetheless, the guide offers substantial help to aid decision making and avoid setbacks. New or experienced PDA users will also appreciate the information about software and online resources that will enhance their use of these devices.


The reviewer has no commercial interest or conflict of interest with any developer of handheld computing equipment or software, but does publish a free monthly newsletter about Palm computing for medical professionals. The Medical Palm Review can be found online at medpalmrev.medtau.org.


Author: Chris Helopoulos
Publisher: Jones and Bartlett

Reviewed by Paul Arnold, MD, MCFP, Emergency Physician, University Health Network;
Faculty, Faculty of Medicine, University of Toronto, Toronto, ON.

February 1, 2004

Editors: Russell K. Portenay and Eduardo Bruera
Publisher: Oxford University Press
Reviewed by: Madhuri Reddy, MD, MSc, FRCPC, Associate Editor.

This text is an evidence-based review of palliative care research and its challenges. Over the last several years, there has been an increasing need for improvements in the scientific basis of palliative care. There is a wide range of types of research in palliative care, including clinical epidemiology, treatment trials, psychosocial research, quality of life studies and systems research. This book examines not only the range of conventional medical interventions, but also a variety of concerns that have mostly been at the periphery, such as ethics, communication and the nature of suffering. The book offers an overview of the most important research issues and includes updated proceedings of a 1998 meeting that focused on research that took place in Washington D.C., at the National Institutes of Health, as well as additional chapters on selected topics.

The book is well organized and is divided into nine sections. The first section focuses on research in the area of pain, and primarily covers methodological issues in the design of pain control clinical trials. It is pointed out that there are many challenges in analgesic trials, including the large placebo effects and difficulty of symptom measurement.

The second section focuses on research on anorexia and gastrointestinal disorders. It reviews information regarding developing, conducting and analysing trials investigating agents for treating cancer-related anorexia/cachexia. Methodological challenges regarding anorexia/ cachexia trials are examined and 10 such trials are reviewed. The final chapter in this section makes the point that little work has been done in the area of anti-emetics, and the author reviews the etiology of emesis and the research that has been published to date.

The third section examines respiratory symptoms research, with a focus on the multidimensional assessment of dyspnea. Because dyspnea is not a single sensation, it is challenging to measure quantitatively. The author reviews some qualitative measures of dyspnea (e.g., visual analogue scale, Likert scales) as well as quality of life instruments. Another chapter in this section reviews research into nonpharmacological interventions for dyspnea. The fourth section looks at research in fatigue/asthenia. It discusses fatigue measurement and causes (e.g., anemia, anxiety, depression) and reviews various interventions and treatments. There is significant discussion surrounding the evaluation of the causal relationships between fatigue and psychiatric symptoms in cancer patients and the respective treatment implications. The fifth section examines neuropsychiatric and psychosocial research. It discusses the undertreatment of depression in the terminally ill, as well as the challenges of quantitative and qualitative measurement of depression.

The sixth and seventh sections inspect quality of life research, including an assessment of decision making capacity and end of life care. The author reviews the medical literature on patient utility, cost utility and effectiveness of using Medline. He reviews the studies defining patient and family member quality of life as well as instruments used to measure quality of life. The chapters on decision making capacity and advance care planning are probably the most useful for physicians involved in geriatrics and care of the elderly research. Even though there is a focus on cancer research, the frequency of cognitive impairment, particularly delirium, in the final days and months of life is also discussed.

The next section examines research in practice change and reviews the barriers to and opportunities for changing end of life care within the medical school environment, as well as in hospitals and cancer centres. The ninth and final section examines research issues in special populations, particularly pediatric palliative care and HIV/AIDS.

Throughout “Issues in Palliative Care Research”, there is little reference to palliative care of older patients, as the book focuses mostly on cancer palliative care. Even the “special population” sections do not include the older population. However, this is doubtless a testament to the paucity of research in this area rather than an omission by the authors. This book is a must for any researcher in the palliative care field. For the rest of us, it is an excellent reference and review of current palliative care research, and the possible future directions of such research.

Editors: Russell K. Portenay and Eduardo Bruera
Publisher: Oxford University Press
Reviewed by: Madhuri Reddy, MD, MSc, FRCPC, Associate Editor.

January 1, 2004

A. Mark Clarfield, MD, FRCPC, Dept. of Geriatrics, Soroka Hospital, Ben Gurion University of the Negev, Beer Sheva, Israel.

Most of us enjoy stories. They instruct, inform, involve and, above all, entertain. Who cannot remember sitting on a parent's lap listening to one. For those of us with enough mild cognitive impairment to cloud recollections of our own youth, surely we can see how much our children and grandchildren appreciate a good yarn. The telling of tales goes beyond the Brothers Grimm, television and the movies, full of (usually awful) stories that continue to attract our attention and empty our wallets.

In medicine, "the narrative" also has great appeal. We take a patient's history, after all, and we have long been told by Sir William Osler that if we let the patient tell us her story, we will come to diagnosis sooner rather than later.

The journals also have caught on to storytelling. The British Medical Journal, Annals of Internal Medicine, Canadian Medical Association Journal and Journal of American Medical Association each offer, respectively, a "Personal Column", "On Being a Doctor", "A Room With a View" and "A Piece of My Mind" in every issue. Of the big five, only the New England Journal of Medicine is still too grey to offer such a column.

Novels also have dealt with medical and doctor-related themes: Thomas Mann explored tuberculosis in "The Magic Mountain", Sinclair Lewis the life of the physician in "Arrowsmith" while Samuel Shem's "House of God" caricatured the life and loves of the harried and harassed house staff. In our field of geriatrics there have been only a few gems. In "The Stone Angel", for example, Margaret Laurence tells the tale from the perspective of an 90-year-old woman.

One of the best books addressing the theme of aging that I have read in many years came off of the pen of Canadian writer Rohinton Mistry. His most recent endeavor, "Family Matters", addresses the many issues of aging through the device of a mildly dysfunctional lower-middle class unit in Bombay. Just shy of 80, the protagonist, Nariman Vakeel, is a Parsi widower and a somewhat powerless patriarch of the family. As long as he is healthy, his stepdaughter Coomy agrees to look after him, not altogether distinterestedly, given that she lives in his house. However, while healthy he really needs very little care.

That being said, Coomy, a most embittered woman, worries constantly lest he fall and do himself an injury. His biological daughter, Roxana, a much sweeter person than her older stepsister, tries to avoid conflicts over their shared pater familias.

"I can't believe my eyes."
"What is it, wrong colour?" asked Roxana, for her sister was superstitious about such things.
"Think for a moment," said Coomy. "What are you giving, and to whom? A walking stick? To Pappa."
"He likes to take walks," said Yezad. [Roxana's husband]. "It'll be useful".
"We don't want him to take walks! He has osteoporosis, Parkinson's disease, hypotension--a walking medical dictionary!"1

All is stable until the old man, suffering from the abovementioned diseases but with absolutely no cognitive impairment, falls and breaks his ankle. Here we are let into the world of Indian medicine--harrowing for members of the lower-middle class who cannot afford health insurance and will not stoop to suffer the care under the terrible conditions of the almost non-existent public health service.

Nariman does spend two days at the Parsi General Hospital for a brief admission to have his ankle set and a cast applied. On his first (and only) night in hospital, Mistry describes the old man's thoughts:

He did not mind being alone. The wardboy on the night shift was an older man, much older than the dynamic day fellow. Early sixties at least, thought Nariman, and wondered if his shaking hands were also due to Parkinson's or something else. He made up for the imperfection of his hands with the perfection of his smile. A smile of enlightenment, thought Nariman, so like Voltaire's in old age, in the portrait that graced the frontispiece in his copy of Candide.

And how did one acquire such enlightenment, he wondered, here, in a grim ward, collecting faeces and urine from the beds of the lame and the halt and the diseased? Or were these the necessary conditions? For learning that young or old, rich or poor, we all stank at the other end?2

On returning home, at first Nariman is cared for by Coomy, but she is clearly not up to the task, neither emotionally nor physically. At first, Coomy and her ineffectual brother Jal tried to move Nariman onto a commode whenever necessary. But it is too much for them. A decision is made to utilize a bedpan and urinal which Nariman "… welcomed… as though they were the vessels of salvation."3 Coomy continues to have trouble coping. As she rightly muses, "It was ridiculous… that with so much technology, scientists and engineers still hadn't invented a less disgusting thing than a bedpan. 'Who needs mobile phones and Internet and all that rubbish? How about a high-tech gadget for doing number two in bed?'".3

The book goes on to tell the tale of how difficult it is to nurse an old man at home with a fracture and Parkinson's disease. And yet, in Mistry's India, there seems to be a glaring lack of any kind of formal services. Gerontologists in wealthy North America inform us that up to 90% of the care of the elderly is borne by the "informal sector". If that is true, then in India it must be 99.99%.

The story is indeed a bleak one, although written with great sensitivity, clarity and beauty. From it we learn how lonely illness can be for an older person and how humiliating and frustrating, especially in the face of a profound absence of expert medical and nursing help.

The book also underlines another theme: how difficult it is for the poor of the world, especially in the less developed countries, to cope with the sick elderly. As well, a novel like "Family Matters" illustrates the universality of the challenges and problems of age-related disease, and how the fate of most of the world's elderly, when they do fall sick, is thrust entirely into the willing or not-so-willing hands of an immediate family. In most parts of the world, for the majority of older persons, there is simply no other choice. Through Nariman's story, Mistry lets us in on this not so well kept secret.

Sources

  1. Mistry, R. Family matters. Toronto: McClelland and Stewart Ltd., 2002, p. 32.
  2. Ibid, p. 56.
  3. Ibid, p. 75.

A. Mark Clarfield, MD, FRCPC, Dept. of Geriatrics, Soroka Hospital, Ben Gurion University of the Negev, Beer Sheva, Israel.

Most of us enjoy stories. They instruct, inform, involve and, above all, entertain. Who cannot remember sitting on a parent's lap listening to one. For those of us with enough mild cognitive impairment to cloud recollections of our own youth, surely we can see how much our children and grandchildren appreciate a good yarn.

September 1, 2003

Geriatric Medicine: An Evidence-based Approach. Fourth Edition
Editor: Christine K. Cassel
Springer-Verlag, 2003.

Principles of Geriatric Medicine & Gerontology
Editors: William R. Hazzard, John P. Blass, Jeffrey B. Halter, et al.
McGraw-Hill, 2003.

Reviewed by: Barry Goldlist, MD, FRCPC, FACP, AGSF, Editor in Chief.

In the past three years, Geriatrics & Aging has reviewed the two major British textbooks of Geriatric Medicine. Dr. Shabbir Alibhai reviewed the 2nd edition of the Oxford Textbook of Medicine in our July/August 2000 issue (Vol. 3, No. 6) and Dr. Christopher MacKnight reviewed the 6th edition of Brocklehurst's Textbook of Geriatric Medicine and Gerontology in our June 2003 issue (Vol. 6, No. 6). Both reviews are still available on our website (www.geriatricsandaging.ca).

Unlike the more balanced international contributions of the British texts, the contributors for the texts Geriatric Medicine: An Evidence-based Review and Principles of Geriatric Medicine & Gerontology are overwhelmingly from one country, the United States, and all the editors are American as well. There are several interesting individuals who have contributed to both texts, and one of these is the distinguished Canadian scientist, Paula Rochon. She has co-authored the chapters dealing with drug usage in the elderly for both texts, certainly an indication of her international stature.

Both texts have similar tables of contents, although the order is somewhat different. The opening section of each text is on the basics of gerontology, and both are quite good. Geriatric Medicine benefits from an initial chapter on evidence-based medicine and its specific application to geriatrics, written by Rosanne Leipzig.

Dr. Alibhai would be pleased to note that both of these textbooks have substantial sections on cancer in the elderly. Some of the chapters in both texts, however, read as though they were written for a standard textbook of medicine, and thus do not address the difficult issues in the field, including how representative the trials are, whether frailty was factored in somehow, and whether there is evidence of age discrimination. Fortunately, both books have an introduction to the cancer section by Harvey Jay Cohen that addresses some of these issues in general. Professor Cohen has more space in Principles of Geriatric Medicine & Gerontology, and thus does a better job there.

The various types of dementia are covered in a rather superficial manner in comparison to the last text I reviewed (Clinical Neurology of the Older Adult, July/August 2003, Vol. 6, No. 7, page 65), but this is a more general text. Geriatric Medicine does a better job with Alzheimer disease, but I suspect that Dr. MacKnight would not be impressed by the sections on vascular dementia in either text (it should be noted that he is a well regarded investigator in this area). I personally feel that the area of cholinesterase therapy is a perfect area for the contributor to discuss statistical versus clinical significance, but neither text addresses that issue. Both texts have chapters on delirium authored or co-authored by Dr. Sharon Inouye and are well written, with as much evidence presented as possible.

Principles of Geriatric Medicine & Gerontology is generally more comprehensive than Cassel's text for cardiovascular disorders, but neither is very strong on the management of atrial fibrillation. I feel a geriatrics textbook should be exploring the barriers to anticoagulation as well as patients' perceptions of treatment, and should be including more detail on the exact benefits in various circumstances to better allow the practitioner to counsel her patients. The Hazzard, et al. text has a larger section on cardiac pacing than it does on atrial fibrillation in the elderly. I suspect that few readers of this text will be making pace-maker insertion decisions, but many will be providing full care to patients with atrial fibrillation.

In summary, these are both excellent texts, each with its own blend of strengths and weaknesses. Both are well written with excellent use of tables and figures. I find that Geriatric Medicine: An Evidence-based Review has an easier typeface to read; however, I would be satisfied with owning either of these two texts.

Geriatric Medicine: An Evidence-based Approach. Fourth Edition
Editor: Christine K. Cassel
Springer-Verlag, 2003.

Principles of Geriatric Medicine & Gerontology
Editors: William R. Hazzard, John P. Blass, Jeffrey B.

August 1, 2003

Editors: Joseph L. Sirven, Barbara L. Malamut.
Lippincott Williams & Wilkins, 2002.

Reviewed by: Barry Goldlist, MD, FRCPC, FACP, AGSF, Editor in Chief.

In this era of rapid medical and scientific advances and with the wide availability of information over the Internet, is the medical textbook still relevant? Some of my colleagues, in their book reviews, have attempted to use the text to answer actual clinical questions that arose in their practice during the period they were evaluating the book. While seemingly quite fair, it avoids the more difficult issue of what type of question we should expect any textbook to answer.

Most practising physicians read a medical textbook for three reasons: to aid them in diagnosing medical disorders, to inform them of the course and prognosis of disease, and to give advice on disease management. I will review how this textbook fulfils these three mandates. In general, for this text a group of distinguished experts (all based in the U.S.) carefully review the available evidence for each topic. The current dogma is that we should distrust expert opinion, but value expert evaluation of the current evidence (e.g., Cochrane Collaboration). This text clearly meets this first hurdle, so on to the three general mandates.

1. Diagnosis of Disease
There are two chapters that lay the basis for the normal aging process and the clinical examination: the neurologic examination of the older adult, and cognitive changes associated with normal aging. These are co-authored by the two editors, and are predictably excellent and refreshingly concise. As well, other chapters lay a strong foundation for dealing with older patients (e.g., imaging of the aging brain, diagnostic tests in the older adult). The chapter on age-related pharmacology is one of the best I have ever seen in a non-geriatric medicine text.

With this basic introduction, how does the text perform? I selected two chapters for a more intense review. The chapter on back and neck pain does have the obligatory table on all causes of back and neck pain, but the text is extremely practical. The issue of comorbidity in the elderly is well handled, as is the issue of adverse effects of specific medications (including cost). The algorithm for management is quite reasonable, and eminently practical. Specific physical examination manoeuvres to help in diagnosis are clearly described--a great help to the non-neurologist.

The second disease entity I selected was dementia with Lewy bodies (DLB). To get a full understanding of the disorder requires reading two chapters (diagnostic evaluation and treatment of dementia and; dementia disorders--behavioural and cognitive aspects), which realistically reflect how a physician would approach a patient with cognitive impairment. The differences from Alzheimer disease and other dementing conditions is clearly expressed and the consensus criteria for the clinical diagnosis of DLB are included in an easy to read table. Diagnostic information for the other dementias is similarly easy to retrieve.

2. Course and Prognosis of Disease
After we give our patients their diagnosis, they quite reasonably want to know what the future holds for them. To answer their questions, a physician must know something of the natural history and treated history of the disease. Once again, I selected two common disorders in the elderly, depression and primary brain tumours. The "naturalistic" course of depression is clearly explained, as are the benefits of both treatment and continuous maintenance therapy. There are similarly excellent discussions on the outcome of brain tumours and the benefits (or lack thereof) of various treatment modalities.

3. Management of Disease

This is the most problematic area for all textbooks. The lag between the writing of a text and its publication always results in newer treatment modalities being missed. The real issues, in my opinion, are as follows:

  1. Are non-drug treatments thoroughly discussed (these tend to change more slowly)?
  2. Are the benefits of current therapies clearly quantified and their pathophysiologic base explained, so that when the reader searches for newer treatments she can put the results of journal articles into the proper context?

For this challenge, I reviewed the chapter on movement disorders in the elderly for the treatment of Parkinson's disease. Although details are not given, the importance of multidisciplinary care and exercise is stressed and placed before the section on pharmacotherapy. The various drugs and their rationale are clearly discussed, and an excellent table is available that summerizes the mode of action, usual dose range, common side effects, warnings and contraindications for the most useful medications. A physician reading a current journal article on management of Parkinson's disease in the elderly would easily be able to put the newest therapy into the proper context.

I think it is clear that I consider this an excellent text. It would be extremely useful for a geriatrician or a family physician involved in health care of the elderly. The book is very specific in its focus on the elderly, and does not attempt to replicate an entire neurology text. Because of this, and its excellent section on psychosocial issues in the elderly, I suspect that general neurologists who care for older adults would also find this a useful textbook.

Editors: Joseph L. Sirven, Barbara L. Malamut.
Lippincott Williams & Wilkins, 2002.

Reviewed by: Barry Goldlist, MD, FRCPC, FACP, AGSF, Editor in Chief.

In this era of rapid medical and scientific advances and with the wide availability of information over the Internet, is the medical textbook still relevant?

June 1, 2003

Editors: Raymond C. Tallis and Howard M. Fillit.
Churchill Livingstone, 2003.

Reviewed by: Chris MacKnight, MD, MSc, FRCPC,
Dalhousie University, Halifax, NS.

The world of the geriatric medicine textbook is a crowded one. Why, then, should one choose this text, which claims to be the leader? For the reasons discussed here, I believe that it would be a good choice.

Brocklehurst's is an attractive work, full of figures and pictures, and there is a nice mix of European and North American authors. An innovation since the 5th edition--one that aids readability--is the addition of summary boxes to each chapter, listing the key points of that chapter. This textbook follows the usual order of most texts in the field, with an introductory section on various features of aging, system-specific sections and then chapters on geriatrics and geriatric services worldwide (there are even a few pages on Canada!). One of my criticisms that applies to most of these works is that they are more texts of the internal medicine of old age than of geriatrics, which I see as the care of the frail older adult. This textbook, however, does concentrate on frailty, with almost every chapter at least nodding towards frailty and the older adult, who suffer with multiple comorbidities and disabilities.

Most texts should accomplish two functions: they should provide an introduction to and comprehensive overview of a field for the novice, and provide a resource for the expert. I recently used this text as a resource for the first few patients I saw on March 3, 2003. My first was a home visit to a patient who had had an episode of syncope. Although there was little information provided on home visits (less than in the 5th edition), there was a detailed and up-to-date chapter on syncope by a recognised world leader in the field. The next consultation was on a woman with Diogenes Syndrome, with the inpatient team wondering about her competency to return home. The section on Diogenes Syndrome was much improved from the 5th edition, and very useful. Unfortunately, I could find nothing related to assessing competency, either in the index or after a hand search of the chapters I thought might be relevant. There also is no chapter on legal issues, although this would likely be difficult in an international text.

I then saw a patient with a postoperative delirium and pre-existing vascular dementia. The chapter on vascular dementia is a great improvement over the section in the 5th edition, where it was lumped in with the other dementias. The section on postoperative delirium also was very helpful and lucid, though there was some repetition between the discussion in the chapter on Delirium and that in the chapter on Surgery.

As with all texts, currency is a problem. There are some references to the 21st century, but not many. New issues, such as West Nile Virus, are nowhere to be found. The editors do recognise this limitation, and realise that for up-to-date information they cannot compete with electronic resources. Where they can compete, however, is in offering a comprehensive overview and foundation, and I believe they have succeeded admirably. This text is useful for trainees, libraries and those healthcare professionals who need either an introduction or a refresher to geriatric medicine.

Editors: Raymond C. Tallis and Howard M. Fillit.
Churchill Livingstone, 2003.

Reviewed by: Chris MacKnight, MD, MSc, FRCPC,
Dalhousie University, Halifax, NS.

The world of the geriatric medicine textbook is a crowded one. Why, then, should one choose this text, which claims to be the leader?

May 1, 2003

Editors: Kantoff P.W., Carroll P.R., D'Amico A.V.
Lippincott Williams & Wilkins, 2001.

Reviewed by: Shabbir M.H. Alibhai, MD, MSc, FRCP(C), Senior Editor, Geriatrics & Aging.

Prostate cancer has been enjoying significant attention in the media over the past few years. Famous individuals such as Health Minister Allan Rock and General Schwartzkopf have been diagnosed and treated in recent years. Much information has been published, in an increasingly compartmentalised and specialised fashion, on the subject in the past decade. This textbook's purpose is to bring together the data from basic science and clinical disciplines in a comprehensive examination of prostate cancer. I should mention at the outset that I have significant research interests in this field, particularly from the geriatric angle, so my perspective on this book may be a little slanted.

To begin with, this reference is written by a host of distinguished American genitourinary oncologists. With very few exceptions, the list of contributors includes the major researchers in the field. Unfortunately, of approximately 100 authors, only two are not American. Thus, a wealth of international (and Canadian) experience in prostate cancer is ignored, and a primarily American perspective on this disease is presented. While this may not be an issue in some fields, in prostate cancer there are significant international differences in thinking with respect to screening, diagnosis and treatment.

The book is organised into eight sections, covering biology, epidemiology, diagnosis, early prostate cancer treatment (two sections), advanced disease (two sections) and future directions. Chapters are generally organised logically, and text and tables are nicely formatted and easy to read. Some chapters have many tables and figures to help facilitate knowledge transfer, whereas others are monotonous and almost exclusively text-based.

The section on biology has some very useful material on anatomy, cellular and molecular biology, genetics and cancer prevention. The anatomy chapter would have been aided by a few diagrams illustrating the anatomy of the prostate in relation to surrounding structures; pity the authors presumed the readers would not find this information useful.

The section on epidemiology is quite interesting. An excellent review of nutritional factors by a world authority includes pertinent sections on vitamins D and E, lycopenes, soy and selenium. However, there is no mention of the ongoing, large SELECT (selenium and vitamin E) randomised prevention trial sponsored by the National Cancer Institute. Peter Albertsen's chapter on age, comorbidity and prostate cancer is particularly relevant to geriatricians and clinical epidemiology-types, such as myself.

Sections 4 and 5, covering single modality and multimodality treatment of localised disease, will be of particular interest to primary care clinicians. There are some useful chapters discussing the role of surgery, external-beam radiotherapy, brachytherapy and combined therapies. One chapter is dedicated to treatment complications such as incontinence and sexual dysfunction, although neither this chapter nor previous ones adequately discuss the risks of treatment complications by modality and patient characteristics. There is also very little discussion of the prevalence of pre-existing incontinence and erectile dysfunction in older adults. This is unfortunate, because both conditions impact upon treatment selection in practice. Moreover, the discussions around treatment do not, in my mind, distinguish the results achieved in specialised tertiary care centres from the average community setting. I found the material on adjuvant hormonal therapy somewhat sparse, given the number of studies published in this area in recent years. I also found the chapter on quality of life long on the theory of quality of life and how to measure it, and short on the actual quality of life after various treatments and complications. This is unfortunate, given the limited evidence in favour of treatment, particularly in older adults, and the major adverse effects of treatment. This is not adequately highlighted.

Chapters in remaining sections cover other interesting areas, including various complications of prostate cancer (hematologic, orthopedic, neurologic), psychosocial issues and a very comprehensive review of pain and symptom management (something with which many clinicians are not very proficient). From an evidence-based medicine perspective, the offerings vary. Some chapters are very careful to discuss the quality and quantity of evidence, whereas others (particularly the chapters on treatment of localised disease) are more cavalier and present the perspectives of expert clinicians with secondary use of studies to justify their positions. Overall, I was disappointed in the offerings, and there was scant mention of several important completed or ongoing clinical trials of management (e.g., the now-published Scandinavian trial of radical prostatectomy vs. watchful waiting and the ongoing PIVOT trial of surgery vs. watchful waiting).

In summary, this textbook will probably be useful to genitourinary specialists (clinicians and researchers) who want quick overviews of specific topics to inform or facilitate more detailed inquiries. Family physicians and general internists should be able to answer most of their questions equally well with a good urology or oncology textbook or a few good review articles on the subject. A stronger focus on methodology (one very good chapter on clinical trials notwithstanding) and evidence-based recommendations would have been an asset. A chapter on informing and empowering patient decision-making also would have been useful, as would a list of Internet-based resources for clinicians and patients. For the generalist, borrowing a copy from your local medical library and waiting for an improved second edition is probably your best bet.

Editors: Kantoff P.W., Carroll P.R., D'Amico A.V.
Lippincott Williams & Wilkins, 2001.

Reviewed by: Shabbir M.H. Alibhai, MD, MSc, FRCP(C), Senior Editor, Geriatrics & Aging.

Prostate cancer has been enjoying significant attention in the media over the past few years. Famous individuals such as Health Minister Allan Rock and General Schwartzkopf have been diagnosed and treated in recent years.

April 1, 2003

Editors: O'Brien J, Ames D, Burns A.
Oxford University Press, 2000.

Reviewed by: Christian Bocti, MD, FRCPC, Cognitive Neurology Unit, Sunnybrook and Women's College Health Sciences Centre, Toronto, ON.

There has been a tremendous increase in the pace of discoveries related to the dementias in the last two decades. For a clinician, it is difficult to keep up with all this new information. Few textbooks on the topic attempt to integrate all fields of knowledge in a comprehensive manner--from basic neurochemistry and neurobiology to clinical approach and neuropsychology, and from pharmacotherapeutic strategies to multidisciplinary management and community services for patients with dementia. Although there are good textbooks available that cover some of these individual aspects, Dementia, Second Edition is the most ambitious textbook presently available, with the many advantages and few drawbacks that such a vast undertaking implies.

The book has 70 chapters (17 more than the first edition) organised in seven parts, which provides a user-friendly structure. There are 133 contributors, mostly from the U.K. but also from continental Europe, North America and Australia. The editors have accomplished a monumental task in coordinating the work of this large number of authors.

General aspects of dementia are reviewed in the first part, which constitutes a full third of this book. Diagnostic criteria for Alzheimer disease (AD), vascular dementia (VaD) and dementia with Lewy bodies (DLB) are discussed, as well as related concepts such as age-associated cognitive decline (AACD). However, the absence of consensus criteria for frontotemporal dementia (FTD) in this section is surprising (they are presented in a later chapter). Clinical aspects of dementia are then presented, including a brief overview of neuropsychology and a more elaborate chapter on neuropsychiatric features. Reflecting the increasing importance of neuroimaging in the differential diagnosis of the dementias, there is a series of chapters that provides a good synthesis of neuroimaging techniques currently in clinical use (CT, SPECT and MRI).

Following, there is an elaborate section on familial, social, cultural and economical aspects of dementia care, as well as a review of services for patients with dementia available in many parts of the world, including developing nations. Most notable are the chapters on sexuality and dementia, and on ethical and legal aspects of dementia care--seldom-discussed issues that can have significant impact on the quality of life of patients.

The second part of the book provides a detailed review of Alzheimer disease, starting with definitions, risk factors and epidemiology. The natural history is described, and the neurobiology section includes very good chapters on the cholinergic system and the neuropathology of AD. Disturbances in other neurotransmitter systems are exposed more succinctly, and genetic factors and even animal models of AD are reviewed in some detail. Therapeutic strategies are presented next, and the use of cholinergic drugs are put in a humbling historical perspective. There also is an extensive review of treatments for behavioural and psychological symptoms, both pharmacological and psychosocial. The chapter on pharmacological approaches provides a well-structured and rational clinical methodology to treating behavioural disorders, with a remarkably comprehensive review of published studies.

The third, fourth and fifth parts of the book cover VaD, DLB and FTD, respectively; all these chapters are written by leaders in the field and provide clear, concise overviews of each entity. Controversial issues, including the importance of leukoaraiosis in cognitive impairment are well discussed. The section on FTD provides good perspective on the different sub-syndromes and clarifies conflicting terminology used by various authors in the literature.

The sixth part briefly reviews neuropsychiatric disorders associated with dementia. The prototypical disorder, Huntington's disease, is well synthesized. There is very little elaboration, however, on dementia in Parkinson's disease. Other chapters provide overviews of cognitive dysfunction in schizophrenia, depression and alcoholism. The inclusion of these chapters in a textbook on dementia is a welcome step forward to a unified conceptualisation of brain-behaviour relationships. The last part provides a brief overview of Creutzfeldt-Jakob disease, HIV-associated dementia and other uncommon dementias.

Overall, this is a comprehensive, authoritative and accessible textbook that anyone involved in the care of patients with dementia will find very useful. It goes well beyond what is found in any other work on dementia, and it presents a good balance of basic science and clinical and psychosocial aspects. In such a wide-ranging text, certain topics are inevitably presented in less detail than others, but globally, this is an excellent textbook. In the decades to come, dementia will become one of the major challenges facing our society and, despite exciting recent developments, there is still much work to be done to meet these challenges.

Editors: O'Brien J, Ames D, Burns A.
Oxford University Press, 2000.

Reviewed by: Christian Bocti, MD, FRCPC, Cognitive Neurology Unit, Sunnybrook and Women's College Health Sciences Centre, Toronto, ON.

There has been a tremendous increase in the pace of discoveries related to the dementias in the last two decades. For a clinician, it is difficult to keep up with all this new information.

February 1, 2003

Editors: Jacoby R, Oppenheimer C
Reviewed by: Dr. Barry Goldlist, Editor in Chief, Geriatrics & Aging.

This text is the third edition of what has become a standard reference text in geriatric psychiatry. Chapters have been updated, often with new authors, and some sections have been deleted (e.g., chapters on nursing and occupational therapy, specialties that now have texts of their own). The book is divided into four sections: basic science, clinical practice, psychiatric services and specific disorders.

The chapters in the section on basic sciences, although necessarily brief, are all excellent. There is evidence of firm editorial control in the way that each chapter is written, particularly in the uniformly excellent concluding remarks. The editors include typical basic science chapters (biology of aging, cognitive changes with aging, neuropathology, neurochemistry, molecular genetics and biology), but also include chapters on sociology, epidemiology and economics. I believe they are excellent additions to the "basic science" of old age psychiatry. I was particularly impressed by the clear and practical discussion on cognitive changes in old age by Milwain and Iversen.

The section on clinical practice describes the clinical skills required to care for mentally ill elderly patients. There are chapters on psychological assessment, neuroimaging, psychopharmacology, social work with older persons, psychometric assessment, dynamic psychotherapy, family therapy, primary care and liaison psychiatry. The two chapters that interested me the most were the first two in this section: psychiatric and clinical cognitive assessment and physical assessment. The first chapter on psychiatric and clinical cognitive assessment was both comprehensive and practical, even discussing issues such as in which room to interview the patient and those about gaining access. The majority of initial psychiatric consultations for the elderly in the United Kingdom are done in the patient's home, and most urgent cases are seen within 48 hours and non-urgent cases within one week. This strikes me as convincing evidence that the U.K.'s system of care for the elderly is more responsive than the Canadian system. The chapter on physical examination is brief, but does cover all the important geriatric issues and highlights the high yield systems to examine. I admit, I was astounded to read that a physical examination was part of the geriatric psychiatry exam in the U.K.

The third and shortest section, covering psychiatric services for the elderly, includes chapters on principles of service provision, caregivers' lives and designing homes and facilities for the elderly with dementia. The last chapter is replete with excellent diagrams and details on what makes a facility appropriate for an elderly person with dementia.

The final half of the book is "hard core" psychiatry, i.e., discussions on specific disorders (e.g., dementia, manic syndromes) and ethical and medico-legal issues in geriatric psychiatry. The chapters on dementia are detailed and written by renowned experts while the other topics, though covered more briefly, are also well done. The chapter on manic disorders in old age is written by two renowned Canadian geriatric psychiatrists, Ken Shulman and Nathan Herrmann.

In summary, this is an excellent textbook of geriatric psychiatry. Despite being a U.K. publication, there are contributors from Canada, the U.S., Australia, Germany, Sweden and Ireland, and the text is clearly applicable to the care of the elderly with mental disorders in North America. This book would be a worthwhile purchase for any physician who deals with such patients.

Editors: Jacoby R, Oppenheimer C
Reviewed by: Dr. Barry Goldlist, Editor in Chief, Geriatrics & Aging.

This text is the third edition of what has become a standard reference text in geriatric psychiatry. Chapters have been updated, often with new authors, and some sections have been deleted (e.g., chapters on nursing and occupational therapy, specialties that now have texts of their own).

November 1, 2002

Editors: Gauthier S, Cummings JL

Reviewed by: Dr. Barry Goldlist, Editor in Chief, Geriatrics & Aging.

As is my usual practice when reviewing multi-authored textbooks, I immediately went to the list of contributors to see how representative they were of the broad community of experts. In this book, only two of the contributors are from countries other than the United States. One of these, Dr. Serge Gauthier, the eminent Canadian neuroscientist, also acts as an editor. Despite this relative imbalance, the book is excellent and of value to any physician with an interest in Alzheimer disease. Specialists and researchers will particularly enjoy the cutting-edge scientific chapters, including one on amyloid processing by Dr. Greg Cole, and Dr. Gauthier's thoughtful perspective on the past failures and future prospects of the use of muscarinic agonists in Alzheimer disease. Any physician, whether primary care provider or specialist, could benefit from the chapters on depression in dementia, the use of antipsychotic drugs in dementia and the management of late stage dementia. I was particularly impressed by the scientific rigour of the chapter on assessing competency for treatment consent capacity and financial capacity by Marson and Briggs.

With any such text, the lag between writing the chapter and publication means that the latest information cannot always be included. The same week that I reviewed this book, for example, I read an article in the Archives of Neurology on increased B-secretase activity in the Alzheimer disease brain that potentially contradicted some of the assumptions about disease pathogenesis in the book's first chapter. Although I enjoyed Professor Schelten's scholarly review of neuroimaging in the evaluation of dementia, I am not sure there is Level 1 evidence for his assertion that one MRI examination during the course of a dementia evaluation can hardly be judged to be optional any more.

Despite these minor quibbles, this is an excellent book that can be profitably read by any physician who cares for patients with dementia, particularly of the Alzheimer type.

Editors: Gauthier S, Cummings JL

Reviewed by: Dr. Barry Goldlist, Editor in Chief, Geriatrics & Aging.

As is my usual practice when reviewing multi-authored textbooks, I immediately went to the list of contributors to see how representative they were of the broad community of experts.

November 1, 2002

by Simon Lovestone and Serge Gauthier, Martin Dunitz, 2001.

Reviewed by Chris MacKnight, MD, MSc, FRCPC, Assistant Professor, Dalhousie University.

When I was asked to review this book I thought, Not another guide to dementia! I was right--this isn't yet another guide to dementia. It is an excellent, helpful and practical book, and one that I greatly enjoyed.

The authors, Drs. Serge Gauthier and Simon Lovestone, are experienced and respected experts in dementia, and they have distilled that experience into 150 easily read and understood pages. Being from both sides of the Atlantic, they bring a nice trans-continental perspective to the book, and their respect for their patients is evident on every page.

The authors don't get bogged down in the minutiae of pathophysiology and pharmacology, but rather present what a practitioner needs to know to get the job done. They begin with a chapter on the newly diagnosed patient, and follow with chapters on common behavioural problems (including one on sleep), treatment of the cognitive symptoms, the possibility of disease modification and, finally, a chapter on long-term care, including the design of the facility.

There are a number of excellent features in this book. The end section contains many instruments commonly used in assessing and following patients with dementia, complete with guides for their use. I particularly enjoyed the cases, scattered throughout the text, that aptly illustrated the management issues and were very real-life. The references at the end of each chapter are both comprehensive and current.

I highly recommend this book to trainees and clinicians (both physicians and non-physicians) who see patients with dementia. Most nursing homes, if not every nursing home ward, should have a copy on hand. Even a specialist is likely to learn something from these pages. Unlike so many books I see, I believe I'll actually use this one.

by Simon Lovestone and Serge Gauthier, Martin Dunitz, 2001.

Reviewed by Chris MacKnight, MD, MSc, FRCPC, Assistant Professor, Dalhousie University.

When I was asked to review this book I thought, Not another guide to dementia! I was right--this isn't yet another guide to dementia.

September 1, 2002

Editors: Norris JW, Hachinski V
Oxford University Press, 2001
ISBN 0-19-513382-X

Reviewed by: Dr. Barry Goldlist,
Editor in Chief, Geriatrics & Aging.

The most common cause of death in elderly people is cardiac disease, and arthritis is the most common cause of disability. However, in my experience, elderly patients fear stroke or dementia more than they do either of these, and with good reason. The consequences of stroke are devastating, and evidence from controlled trials of educational interventions in atrial fibrillation suggests that patients are eager to do anything that will reduce their risk of stroke. Yet, in developed countries only about 20% of people with hypertension (the most common risk factor for stroke) have their disorder diagnosed and effectively treated. Similar statistics are seen for other risk factors such as atrial fibrillation. Therefore, there is no doubt that continuing efforts in stroke prevention are required, which is the focus of this superb book.

The two editors are both Canadians, and the contributors come from Canada, Great Britain, the United States, continental Europe, Israel and Australia. The inclusion of a contributor from the World Health Organization ensures that the issue of stroke prevention in developing countries is not ignored.

The text is divided into three parts: Primary Prevention; Secondary Prevention; and Prevention: Policy and Practice. The emphasis is on an evidence-based approach. However, the style of each chapter (presumably the influence of the editors) is quite accessible to all readers because the technical terms are clearly defined. This makes the evidence easier to understand for the reader who is not an expert in critical appraisal, without sounding condescending. The list of references for each chapter is voluminous, and considering the publication delay, surprisingly up-to-date (the chapter on carotid angioplasty and stenting includes a reference from the year 2000). The introduction and epilogue by the editors are superb, the former providing a clear outline of the important information on stroke prevention, and the epilogue outlining difficulties in implementing proven strategies as well as future directions.

This book is a 'must read' for those with a particular interest in stroke prevention, and certainly worth having on the bookcase for reference. I think it is also a very useful text for primary care physicians who see older patients. Its careful presentation of the evidence will allow practising physicians to transmit to their patients the type of information that might convince them to try to prevent stroke. Any physician dealing with older patients would benefit, at a minimum, from reading the prologue and the epilogue to this outstanding text.

Editors: Norris JW, Hachinski V
Oxford University Press, 2001
ISBN 0-19-513382-X

Reviewed by: Dr. Barry Goldlist,
Editor in Chief, Geriatrics & Aging.

The most common cause of death in elderly people is cardiac disease, and arthritis is the most common cause of disability. However, in my experience, elderly patients fear stroke or dementia more than they do either of these, and with good reason.

August 1, 2002

A Mark Clarfield, MD, FCFP, FRCPC

As a geriatrician, I was initially put off by the idea of a book full of interviews with famous people&emdash;just because they had attained "a certain age."

But I was wrong.

"Of a Certain Age" by Naim Attallah (Quartet Books, 1992) is well worth the read. The 14 people featured all have had fascinating pasts. They are now quite old (average age 70) and are just as--perhaps more--interesting for having aged so well.

Mostly Bruits, they represent primarily the English uppercrust--a group once described by a wag as "a bunch of crumbs held together by dough."

And some are indeed crumbs--Clause von Bulow and Lady Diana Mosely are two excellent examples. Many are wealthy, but all are worth the listen. There are professors, judges, writers, publishers and sophisticated hangers-on--all expertly interviewed by the British writer and publisher Naim Attallah.

I am not the kind of Jewish reader who divides up members of humanity depending on their attitudes towards my ethnic group. However, in this book it is difficult not to be struck by how these old grandees self-differentiate so clearly into two groups: anti- and philo-Semitic.

At one end of the spectrum stands Diana Mosely, one of the celebrated Mitford girls and the wife of Oswald Mosely, leader of the wartime British Union of Fascists. Today, she lives a quiet, unrepentant life in southern France. Her interview really is a bit awe-inspiring. In it, Lady Diana speaks in such a matter-of-fact manner about her close relations with things Nazi.

For example, relating to her friendship with Hitler. "Unity (Diana's sister) loved and adored him, thought him utter perfection. I never felt like that about him but I did admire him very much for what he had done."

Standing in stark contrast is the Irish politician, writer and editor, Conor Cruise O'Brien.

He is so unabashedly on the side of the Jews: "...[My] degree of sympathy for Israel is based on the realization that Israel is the result of horrendously extreme conditions ... it's an emotional issue with me."

A more "balanced" view is noted by many of those interviewed.

For example, Lord Deedes, an eminent Member of Parliament and publisher, in describing his father's views:

"He had what you might call the Edwardian, old Eton conscience, and I look back on him as a very respected Christian socialist. He was left of centre for what might be described as inner reasons rather than ideology.

"There was one period, for example, when he bought every book he could lay his hands on about Mussolini. There was an endearing enthusiasm about my father's political beliefs and in the early stages he even thought Hitler might do Germany a bit of good."

Another experience, which so many of these famous oldsters seem to have in common, was that of an unhappy childhood and/or a fearful disdain for their parents. Return for a moment to Lady Mosely, not unlike many children of her time and class: "In a way, the person who meant most to me ... was my nanny. I loved her far more than I did my parents.."

[Far more bizarre experiences seemed to have "dogged" young Diana. In answer to a question relating to her father who on occasion would chase the children with the family canine: "I don't think that he was nearly as eccentric as people imagine. You see, he had a bloodhound, and it was rather fun to hunt with him. And we children were there, available…"

She goes on to reassure us that "he didn't hunt us very often... and in any case the bloodhound died."]

A less bizarre, but equally characteristic description of the childhood suffered by so many of the upper class comes from Lord Deedes. He is ashamed "to this day" that his relationship with his own son did not differ significantly from the cold and distant rapport Lord Deedes had with his own father.

"Frankly I was neglectful and I treated my children as my father treated me." And so typical of his generation and class: "...of course, there were nurses and governesses to look after them."

The oh-so-Anglo temperament of these old-timers is much in evidence. Their command of the Queen's English is one of the delights of the book. (And keep in mind that these are merely interviews.) For example, take Lord Deedes once again. In describing a pessimistic view of mankind, he characterizes our species as "being born to trouble as the sparks fly upwards."

There are also many examples of the classic British use of understatement. One of those interviewed, by any estimate a brilliant and supremely accomplished man, is asked a question about his weaknesses. The response: "Every now and again, I get mildly alarmed at the extent to which someone of my rather limited intellectual capacity has succeeded in doing certain things."

The interviewees in the book are all old people and surprisingly, a few have some interesting things to say about aging. One elderly lady talks about a fear greater than that of dying itself: her concerns relating to the manner of her death.

"I'd like to be somebody with a weak heart and then I could simply have a heart attack. But alas, it won't be like that."

Publisher John Murray is asked if he is more or less certain of his opinions as he ages. He responds, "Less sure" and goes on to offer a beautiful quote by Goethe on the subject:

"To be uncertain is uncomfortable, to be certain is ridiculous."

He offers another tasty little quote on the subject of aging: "Man is not old when his teeth decay. Man is not old when his hair turns grey. But man is approaching his last long sleep when his mind makes appointments his body cannot keep."

On the question of the possibility of an afterlife, one that I am sure becomes more pressing with age, Lord Shawcross (chief British prosecutor at the Nuremberg trials) offers the following delightful response:

"It may be that as I get nearer the end [he was 90 at the time of the interview], I become more hopeful that the end will not be final, that there might be something beyond it. But it doesn't absorb much of my thinking even now. All I can say is that I have a little hope that I may meet 'round the corner' those who have preceded me."

The same Lord Shawcross goes on to confirm my non-clinical impression that mourning for a beloved spouse often goes on much longer than is commonly supposed, even among those who are well adjusted:

"My enthusiasm for life did rather come to an end with the death of my second wife, which did come as a terrible shock to me."

And, in response to whether he believes he will ever see her again: "I hope I may. I carry in my pocketbook, even today, something that one sees quoted much more often in memorial services: 'Death is nothing at all. I have only slipped away into the next room. I am I and you are you. What we were to each other we are still. Call me by my familiar name.'

Not surprisingly, given the age of those interviewed, some will have had some interesting childhood memories of people long dead, and places inexorably changed. A particularly evocative example relates to John Murray (the sixth in a line of namesake publishers).

His grandfather (John Murray IV) was ill and young John was a schoolboy home on holiday. Grandad mentioned that a distinguished author was coming to visit.

John IV to John VI: "I think Sir Arthur Conan Doyle is calling today. Will you be kind to him? I hope he may be bringing another typescript."

Conan Doyle did, in fact, come that day, to deliver the very last volume of the Sherlock Holmes stories, and, "I was so staggered by this distinguished man's courtesy to a young whippersnapper like me that I thought: if this is an author, let me spend my life with authors."

And he did.

Also on the issue of aging, we read one of the funniest lines in the book. Lord Soper is quoted as stating that the continued existence of the House of Lords has, among other things, reaffirmed his belief in life after death.

The question for Canadian readers, of course, is whether milord's comments are relevant to our own Upper House.

One of the most poignant expressions, also by Lord Soper, happens to be contained in the last two sentences of the book. In answer to whether he had any regrets, his Lordship responds: "An infinite number. At my age one's sense of failure in the past is an interesting and solemnizing experience. You haven't much time in which to put things right. Which makes me say better prayers than I used to."

This book is a lovely read. Especially if you are interested in the wisdom (and sometimes cant) of an extraordinary stable of old people who aged along with the past century.

Dr. Clarfield, MD, FRCSC, is the Chief of Geriatrics, Soroka Hospital Centre, a Professor and Sidonie Hecht Chair of Gerontology, Faculty of Health Sciences at Ben Gurion University of the Negev in Beersheva, Israel , and an Adjunct Professor in the Division of Geriatric Medicine, McGill University and Jewish General Hospital, Montreal, QC.

A Mark Clarfield, MD, FCFP, FRCPC

As a geriatrician, I was initially put off by the idea of a book full of interviews with famous people&emdash;just because they had attained "a certain age."

But I was wrong.

"Of a Certain Age" by Naim Attallah (Quartet Books, 1992) is well worth the read. The 14 people featured all have had fascinating pasts.

June 1, 2002

Harrison's Principles of Internal Medicine, 15th edition

Editors - Eugene Braunwald, Anthony S. Fauci, Dennis L. Kasper, Stephen L. Hauser, Dan L.Longo, J. Larry Jameson

Reviewed by: Shabbir M.H. Alibhai, MD, MSc, FRCPC, Senior Editor, Geriatrics & Aging.

How does an internist go about reviewing a textbook such as Harrison's? A copy of Harrison's has been with me since I began medical school, which already says something, although I'm not sure exactly what. Certainly when one thinks about a short list of great Internal Medicine texts, this book comes to mind. I suspect that almost every reader has encountered Harrison's in one way or another during training or practice. Thus, I approached this review slightly differently. I examined my clinical Internal Medicine practice in the last month to select the last six questions where I required additional information and thought it fair to consult a textbook rather than a specific study. I then evaluated the 15th edition of Harrison's with respect to its ability to answer these questions. The questions were as follows:

  1. In a patient with an elevated growth hormone level, how does one go about making the diagnosis of acromegaly?
  2. What is the best non-invasive test for an older patient with clinically suspected renal artery stenosis?
  3. Which physical exam maneuvres are useful in diagnosing aortic stenosis?
  4. Which groups of patients benefit from perioperative beta-blockers?
  5. How does one treat a patient with relapsed polymyalgia rheumatica (PMR)?
  6. What is the role of testosterone in the treatment of male osteoporosis?

In general, the text is well laid out, and the index is detailed and reasonable to navigate through. The 15th edition maintains the traditional layout of chapters, although in comparison to an earlier edition, there is a larger chapter on genetics and the somewhat sparse chapter on psychiatry has been subsumed in the chapter on neurology. As usual, I was dismayed to find no chapter or even section devoted to geriatrics and related issues (such as the biology of aging organ systems). The text is clear. Tables, charts, figures and flowsheets abound (even more than in previous editions), and there are new symbols to highlight specific headings such as genetic considerations and treatment (although there is no symbol for diagnosis, which is a pity).

So how did it do in terms of my queries? With respect to the question of acromegaly, Harrison's had nice sections on etiology, presentation and diagnosis. It discussed the role of both growth hormone and IGF-1 in screening and the utility of the glucose tolerance test to help rule in or rule out the diagnosis. Unfortunately, there was no mention of the test characteristics (i.e., sensitivity, specificity) but there was a good reference in the bibliography. With respect to the diagnosis of renal artery stenosis, the material provides a useful algorithm (although only in text form) to make the diagnosis, and actually includes some information on the sensitivity and specificity of magnetic resonance angiography as the best non-invasive test (although it does not provide comparative information for other non-invasive tests). When it comes to physical examination of aortic stenosis, classic findings are described, although the emphasis on detailed physical exam is less in this edition, perhaps reflecting the general decline in popularity of physical examination in modern medicine. What is lacking is information about the utility of any specific physical exam maneuvres in ruling in or ruling out aortic stenosis, which would have been more valuable to me than simply listing some common findings in the JVP, the pulse or the apical impulse.

On to therapeutics. After a frustrating time searching for a discussion of perioperative beta-blockade, I found nothing mentioned about this topic. Perhaps I missed it, but it was neither in the index, the table of contents nor selected portions of the text I examined. Moreover, I noted an absence of any section dedicated to preoperative assessment of patients, which was a clear deficiency. With respect to relapsed PMR, I was surprised to find no separate section for PMR. There was little mention of PMR under temporal arteritis either. There was no information on how to treat relapsed temporal arteritis. Finally, with respect to the use of testosterone in male osteoporosis, there was no mention of testosterone as either a standard or an experimental agent to treat osteoporosis, despite considerable recent interest and a small but accumulating body of evidence. For that matter, the discussion on male osteoporosis was virtually non-existent.

At the end of the day, my assessment of the current edition of Harrison's was less than flattering. Perhaps my questions were esoteric or my standards were too high; I will leave that up to the reader to judge. For myself, I would still keep a copy of Harrison's on my shelf, but I am not sure when I would update my older edition and how often I will use this edition. The information in Harrison's is great for summarizing rare diseases and discussing well known aspects of common diseases. But practical information with respect to diagnosis and management was less than I was looking for, despite over 2600 pages of information. And, the lack of emphasis on quality and quantity of evidence was rather disheartening. Maybe it's time to look at online versions of classic texts.

Harrison's Principles of Internal Medicine, 15th edition

Editors - Eugene Braunwald, Anthony S. Fauci, Dennis L. Kasper, Stephen L. Hauser, Dan L.Longo, J. Larry Jameson

Reviewed by: Shabbir M.H. Alibhai, MD, MSc, FRCPC, Senior Editor, Geriatrics & Aging.

How does an internist go about reviewing a textbook such as Harrison's?

June 1, 2002

Orion Books Ltd, London, 1999; 277 pages with index
Reviewed by: A Mark Clarfield, MD, FCFP, FRCPC

As a geriatrician, I did not expect to learn a lot from a book on aging written for the intelligent layman. But I was wrong.

Tom Kirkwood, one of the world's foremost researchers into the study of human gerontology, has written a book that looks deeply and clearly into this fascinating subject--which he rightly calls "one of the last great mysteries of the living world." And, as I tell my medical students, whoever unlocks this secret will no doubt be a candidate for the Nobel Prize in Medicine.

In the preface of this slim volume [Time of Our Lives: Why Ageing is Neither Inevitable nor Necessary] Kirkwood lists the questions that he promises to answer: Why do we age? How does aging happen? Why do some species live longer than others? Do some parts of the body wear out sooner than others? Why do women live longer than men? Why do women have a menopause half way through their life span?

Even if the above-listed puzzles interest neither you nor your patients, this final one should exercise us all, "Can science slow my aging process, or help me age better?" We may not want to grow old, but as a wag once put it, "I prefer old age to the alternative." And, if most of us will try to postpone this particular alternative for as long as possible, how can we hope to age "successfully?"

On the latter subject, the self-help shelves of your local Chapters outlet fairly groan with books touting all kinds of nonsense on the subject. But if you want a clear, concise and scientific answer to the last question for you and your patients, read this book.

Early on, Kirkwood dispels a pernicious notion that unfortunately many gerontologists milk for all it's worth; that is, that the demographic changes we are observing constitute some kind of a catastrophe. That soon the world will comprise a majority of balding cripples demanding an ever increasing portion of the health and social services budgets. As Kirkwood puts it, "There is an unfortunate tendency to see the graying of the world's population as a disaster in the making instead of the twofold triumph that it really is. Firstly, we have managed --not a moment too soon--to begin to bring soaring population growth numbers under control. Secondly, we have succeeded --through vaccination, antibiotics, sanitation, nutrition, education and etc-- in bringing death-rates down."

One of his major points is that despite the rapid increase in the growth of the 80 plus age group, there is increasing evidence (originally from the United States but now supported by Canadian and European data)1 that the period of sickness and disability concentrated at the end of life is actually getting shorter, not longer, as life span increases. These new data add further support to the optimistic prognostications of Crapo and Fries' "Squaring of the Curve" hypothesis.2 In sum, this theory suggests that while maximum life span has not changed much over the past few millenia, average life expectancy (at every age) has increased in the last two hundred years. More to the point, healthy life expectancy has lengthened so that more and more old people are living longer and healthier lives, with the period of end-of-life disability shrinking concomitantly.

One of the most interesting chapters, entitled "What's in a Name?", attempts to define aging and to distinguish it from disease--not an easy task. And Kirkwood admits that despite our supposed familiarity with the process, "…the precise concept of ageing is slippery to grasp, like a bar of soap in a bath." He begins by quoting a British biology professor, J.M. Smith, "Ageing is a progressive, generalized impairment of function resulting in an increasing probability of death."

But we cannot make much sense out of this definition until we understand why we age and how our cells, organs and body gradually lose function. This chapter begins, as do all in the book, with a relevant, pithy quote, in this case from Eubie Blake, the famous jazz musician, on reaching age 100: "If I'd known I was gonna live this long. I'd have taken better care of myself."

Kirkwood attempts to answer the "why" question by elucidating his now famous "disposable soma" theory. The fact that all mammalian species have a fixed maximal life span (e.g., rat: 4 years, elephant: 70 years, Homo sapiens: 120 years) was adduced to support the hypothesis that we are all endowed with "killer" genes, activated by some kind of an internal clock. According to this school of thought, when our time is up, our genes do away with us.

However, Kirkwood does not accept this theory and musters impressive data to refute it. He explains that it is not our genes that actually destroy us--this does not make biological sense. Rather, their function from the evolutionary point of view is actually to keep us going for as long as possible. In the end, it is our bodies (the soma) and not our genes (germ-line) which are disposable. The genes have evolved to invest "…enough in maintenance to enable the organism to get through its natural expectation of life in a wild environment in good shape." From an evolutionary point of view, from which Kirkwood and others insist we must view aging, more than this minimal investment is a waste.

Furthermore, the theory goes on to suggest that there may be design constraints which favour the organism when young at the expense of its long-term durability. A good example would be the central nervous system's once-only development of a fixed network of neuronal connections set down early in life. Despite cell loss over the years and a lack of the usual repair mechanisms, which are present in many of the rest of our organs, the expanded human brain works well for nearly a century but finally begins to "break down" in very old age.

In the end, "natural selection in the wild is not much concerned with late-acting mutations, which may accumulate unchecked within the genome."

He also clarifies the fascinating connection between aging and cancer. After all, the incidence of most tumours rises asymptotically with age and both involve cellular regulatory systems. At first, Kirkwood disposes of the notion that aging is some kind of anti-cancer mechanism:

"It is not. And yet there is a real connection between ageing and cancer, which has, I believe, much to do with the fundamental distinction between the germ-line and the soma. Somatic cells are cheaply made and disposable, but each somatic cell contains within itself the genetic wherewithal to become germ-like again. Cancer is an accidental reversion to a germ-like state."

Therefore, Kirkwood continues, "The same general mechanisms that protect against cancer protect against ageing. This is why long-lived species [such as Homo Sapiens], with their better cellular protection, get cancer later than short-lived species [such as the rat]."

This book explains a complex and fascinating subject with both clarity and panache. Kirkwood, an accomplished scientist, also enjoys the unusual ability for such a professional of being able to write clearly and well. For example, in describing the semelparous form of reproduction (familiar to us through the antics of the salmon) where the parent gives birth and then dies shortly thereafter, he describes in some detail the case of the octopus.

After the babies hatch, the female octopus loses interest in feeding herself and dies shortly thereafter. Kirkwood writes: "In the case of the mother octopus, it is not at all clear why she does not resume normal feeding when the little octopuses hatch. It is not as though she is rushed off her feet&emdash;all eight of them&emdash;ministering to her little one's needs. All she does is die."

Another example of his way with words relates to the menopausal pituitary's upsurge in FSH and LH in an attempt to get the aging ovaries to cycle once again. As Kirkwood puts it, "…the glandular equivalent of yelling over the telephone at someone who is deaf."

My favourite example of his literary style involves Kirkwood's description of the sperm, the main job of which, as we know, is merely to race up the Fallopian tubes seeking out an egg to fertilize. "…and it is therefore no surprise that sperm have evolved to become little more than DNA packages with big outboard motors."

Aging is a fascinating yet paradoxically still understudied subject. Perhaps like its related subject death, we tend to deal with the topic via the psychological mechanism of denial. But how and why we grow old is too interesting and too influential a subject to be ignored for much longer. Kirkwood's book is a good beginning for anyone interested in what will inevitably happen to them and their patients.

And, of course, we must never forget that aging is a process, indeed a long drawn out and relative one. As Oliver Wendell Holmes at age 92 had to say on seeing a pretty girl pass by, "What I wouldn't give to be seventy again!"

Dr. Clarfield, MD, FRCSC, is the Chief of Geriatrics, Soroka Hospital Centre, a Professor and Sidonie Hecht Chair of Gerontology, Faculty of Health Sciences at Ben Gurion University of the Negev in Beersheva, Israel , and an Adjunct Professor in the Division of Geriatric Medicine, McGill University and Jewish General Hospital, Montreal, QC.

References

  1. Jacobzone S. International challenges: what are the implications of greater longevity and declining disability levels? Health Affairs 2000; 19: 213-25.
  2. Fries JF. Aging, natural death, and the compression of morbidity. N End J Med 1980;303: 130-5.

Orion Books Ltd, London, 1999; 277 pages with index
Reviewed by: A Mark Clarfield, MD, FCFP, FRCPC

As a geriatrician, I did not expect to learn a lot from a book on aging written for the intelligent layman.

May 1, 2002

Seventh Edition. McGraw-Hill 2001.

Reviewed by: David J. Gladstone BSc, MD
Fellow, Division of Neurology, University of Toronto.

The collaboration between Raymond Adams and Maurice Victor dates back to the early 1950s at Massachusetts General Hospital and includes over 100 co-authored papers with seminal descriptions of alcoholic cerebellar degeneration, Wernicke-Korsakoff syndrome, central pontine myelinolysis and normal pressure hydrocephalus. Now in its seventh edition, their Principles of Neurology remains a classic text.

This single-volume work summarizes the core of clinical neurology. The organization follows a logical sequence from "symptom to syndrome to disease." The first half of the book deals with the cardinal manifestations of neurologic disease; the second part is devoted to the major neurologic disorders. The book is strong in its clinical descriptions, classifications and diagnostic approach.

In this era of multi-authored and multi-edited textbooks, the limited authorship of Principles of Neurology is a unique accomplishment that distinguishes this book from many others currently available. It is co-authored with Allan Ropper, Professor of Neurology at Tufts University School of Medicine.

The book has appeal for medical students, trainees and clinicians in general practice, internal medicine, geriatrics, psychiatry and neurosurgery. Many practicing neurologists have a personal copy of this text on their bookshelf but need to consult more exhaustive, multi-volume references for the minutiae. A practical pocket companion book is available separately and may be particularly suitable for students and housestaff.

As so much of neurology involves geriatric medicine, practitioners involved in the care of the elderly will find this book to be a valuable resource. Sections of particular interest to the geriatrician are chapters on The Neurology of Aging, Degenerative Diseases of the Nervous System, Delirium and Other Acute Confusional States, and Disorders of Stance and Gait, among others. General practitioners will find useful sections on seizure disorders, cerebrovascular diseases, tremor and other movement disorders and painful neurologic conditions. Psychiatric illness and neuropsychiatry are given special prominence based on the authors' "belief that these diseases are neurologic in the strict sense." Chapters on pediatric, developmental, metabolic and inherited neurological disorders are also included.

The field of neurology continues to advance at rapid pace and this revised edition is updated with knowledge gained over the past four years, during the culmination of the Decade of the Brain. However, in certain places I found the coverage of neurologic therapeutics to be incomplete or outdated, such as the discussion of Alzheimer disease pharmacotherapy. Readers looking for in-depth discussion of current treatment specifics may need to consult other sources. Neuroimaging and (black-and-white) illustrations are relevant and useful, although the ratio of text to figures is high. Many of the tables are excellent. Additional photographs, imaging scans and colour may enhance future editions.

With the passing of the Canadian-born Maurice Victor on June 21, 2001 at the age of 81 years, this textbook is a legacy of his lifetime of contributions to the practice and teaching of neurology.

Seventh Edition. McGraw-Hill 2001.

Reviewed by: David J. Gladstone BSc, MD
Fellow, Division of Neurology, University of Toronto.

The collaboration between Raymond Adams and Maurice Victor dates back to the early 1950s at Massachusetts General Hospital and includes over 100 co-authored papers with seminal descriptions of alcoholic cerebellar degeneration, Wernicke-Korsakoff syndrome, central pontine myelinolysis and normal pressure hydrocephalus.