Book Review

Clinical Diagnosis and Management of Alzheimer's Disease

N Engl J Med 2007; 357:725-726August 16, 2007

Article

Clinical Diagnosis and Management of Alzheimer's Disease
Third edition. Edited by Serge Gauthier. 393 pp., illustrated. Abingdon, England, Informa Healthcare, 2007. $179.95. ISBN: 978-0-415-37299-2

It has been estimated that the number of persons with dementia in the world will increase fourfold during the next four decades because of an increase in the number of elderly persons worldwide. Most cases of dementia will occur in the developing world. Because most are thought to be related to Alzheimer's disease, either alone or in combination with other brain disorders, a comprehensive, practical textbook on the management of dementia is warranted. The third edition of Clinical Diagnosis and Management of Alzheimer's Disease is such a book. The previous edition was published in 1999; this new edition has been almost completely rewritten, with new contributors writing many of the chapters.

The book deals only briefly with molecular genetics, neuropathology, and other basic scientific aspects of the disease. Although no major breakthroughs have occurred in the study of Alzheimer's disease since the publication of the previous edition, and although no major new treatments or diagnostic tools have been introduced, important refinements in clinical practice have been developed. Advances in medical management are covered in four new chapters that address the different stages of the disease: the very early stage (also known as mild cognitive impairment), the mild-to-moderate stage, the severe stage, and the terminal stage. The treatment of symptoms is prescribed mainly at the mild-to-moderate stage and to a certain extent at the severe stage. No drugs have been approved for the treatment of patients in the very early stage of the disease.

Alois Alzheimer.

The editor and authors of this book recommend that clinicians use information from observational epidemiologic studies that suggests that a healthful diet, intellectual and physical activity, and the treatment of vascular risk factors may protect against dementia. They also point out that even if randomized trials do not show that these measures are effective, it is not harmful to advise patients to adopt a healthful lifestyle or to detect and treat vascular risk factors. Although only the symptoms of Alzheimer's disease can be treated, it is important to manage behavioral and psychiatric symptoms as well as concomitant medical illnesses — a point that is highlighted in several excellent chapters.

The diagnosis of cognitive impairment and dementia is also discussed, and several chapters on clinical assessments are included. Bedside evaluation is still the most important tool in the diagnostic workup, and it is complemented by structural brain imaging and blood tests to exclude other causes of cognitive dysfunction. Neuropsychological testing complements bedside assessment by providing a more detailed picture of cognitive dysfunction. The increasing use of cerebrospinal fluid markers in diagnosis is acknowledged by the inclusion of a new chapter on biologic markers. Yet the utility of most markers is hampered by the overlap between Alzheimer's disease and normal aging and between Alzheimer's disease and other disorders associated with dementia. This is not surprising, because up to 50% of elderly persons who fulfill the neuropathologic criteria for Alzheimer's disease do not have dementia, and a large group of elderly patients have mixed pathologies — usually Alzheimer's disease and another kind of cerebrovascular disease. Another problem highlighted in several chapters is the heterogeneity among patients with Alzheimer's disease; this heterogeneity suggests that the disorder may include several subtypes that are not yet known.

This book includes comprehensive chapters on almost every aspect of the management of Alzheimer's disease, including support of the caregiver, ethical issues, and genetic counseling. Its approach is clinical and hands-on. The only topic that I thought was missing was dementia in the developing world. Considering the demographic changes in world populations, this should be an essential part of all future international textbooks on the topic. Despite this criticism, Clinical Diagnosis and Management of Alzheimer's Disease is an essential handbook for clinicians, including geriatricians, psychiatrists, neurologists, internists, and general practitioners who deal with patients with Alzheimer's disease and other disorders associated with dementia.

Ingmar Skoog, M.D., Ph.D.
Göteborg University, SE-413 41 Göteborg, Sweden
ingmar.skoog@neuro.gu.se