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BOOK REVIEW |
Professor of Psychology, Gerontology, and Preventive Medicine University of Southern California Los Angeles, CA 90089
Alzheimer's from the Inside Out, by Richard Taylor. Health Professions Press, Baltimore, MD, 2007, 255 pp., $18.95 (paper).
Defying Dementia: Understanding and Preventing Alzheimer's and Related Disorders, by Robert Levine. Praeger Publishers, Westport, CT, 2006, 219 pp., $34.95 (cloth), $38.50 (Ebook).
Geriatric Neuropsychology: Assessment and Intervention, edited by Deborah K. Attix and Kathleen A. Welsh-Bohmer. Guilford Publications, New York, 2006, 467 pp., $65.00 (cloth).
Neurocognitive Disorders in Aging, by Daniel Kempler. Sage Publications, Thousand Oaks, CA, 2005, 329 pp., $109.00 (cloth), $57.95 (paper).
We truly do not know how much of dementia is preventable or, once dementia has been discerned, how much its course can be held back. Public attention and public worry are increasingly apparent. The MetLife Foundation reports that among Americans aged 55 and older, Alzheimer's disease is the most feared condition on a list of illnesses—with Alzheimer's disease chosen by 31 percent of respondents, compared to 27 percent choosing cancer and 20 percent choosing stroke (Harris Interactive, 2006). The Alzheimer's Association issued a press release to introduce a new report emphasizing that over 5 million Americans now have Alzheimer's disease, with 11 to 16 million cases projected by 2050 unless there are significant scientific gains in prevention and treatment (Alzheimer's Association, 2007).
There is a growing movement, paralleling the anti-aging industry, that offers mental exercises, special diets, and so forth as a means for dementia prevention. Often the recommendations seem to outdistance available empirical evidence. In writing about things that can be done, there is also considerable blurring of potentially germane distinctions—the difference between interventions aiming to prevent dementia and interventions aiming to maintain optimal cognition among non-demented elders, as well as the difference between interventions aiming to prevent dementia and interventions aiming to slow decline among those already demented.
The books discussed in this essay address these and related issues. Each of the books offers a distinctive voice, and each is written to a somewhat different audience. But there is important convergence with respect to providing the reader with evidence-based information. Richard Taylor, author of Alzheimer's from the Inside Out, is unusual in writing from the point of view of a psychologist who has been diagnosed with Alzheimer's disease. Robert Levine, author of Defying Dementia: Understanding and Preventing Alzheimer's and Related Disorders, is a neurologist—a former chief of neurology and a retired clinical professor—with a wealth of case material on which he draws. Daniel Kempler, author of Neurocognitive Disorders in Aging, is a scientist, a clinician, and an educator, with a background in linguistics and in communication disorders. Deborah Attix and Kathleen Welsh-Bohmer, editors of Geriatric Neuropsychology: Assessment and Intervention, are clinical neuropsychologists with expertise spanning neuropsychological assessment, cognitive training, and clinical research.
Taylor's essays are an important reminder that there is a point of view held by the person with Alzheimer's disease. He describes waiting for a diagnosis, being given a neuropsychological test battery, and being prescribed the current medications for Alzheimer's disease. He conveys the frustrations of a diagnosis that includes the word "probable" and of living with a disease whose causes and progression are not fully understood. Taylor also discusses the power of the dementia diagnosis to alter human interaction, the stigma, the ways in which others turn him into an object or a child. He offers unvarnished descriptions of his own fear: what it is like to live with gaps in one's memory, to be dependent on others, to revise the relationship with one's spouse, to feel oneself changing, to lose control. He describes two extremes in how others interact with him, neither of which is helpful: Because he can maintain a conversation and can use the Internet, well-intentioned friends reassure him that he must not have dementia. Or, because people know that he has Alzheimer's disease, they speak to him loudly or they stop relating to him directly and only talk to his caregiver.
Although Taylor's intended audience is others in the same situation as himself, caregivers and clinicians need to hear what this writer is saying. His essays with advice to MDs apply equally to other professionals working with dementia patients; for example, speak to the patient, not just to the family member as if the patient were not in the room; have a limited number of issues that are the focus of the consultation and make sure that the patient can repeat the points back in his or her own words.
Geriatric Neuropsychology devotes a chapter, by Joanne Green to providing feedback about the results of neuropsychological testing. It is revealing to read this chapter together with Taylor's essays. Paralleling Taylor, Green emphasizes including the patient at the meeting and encouraging the patient and family to speak as well as listen. Green recognizes that these meetings can be very difficult for both patient and practitioner and offers guidance for the neuropsychologist. In case there were any doubt, Taylor's essays about his own experiences highlight the importance of these meetings and the need not to treat this phase of evaluation as an afterthought.
What can be said to those who want to reduce their personal odds of becoming demented? Levine's Defying Dementia is written to encourage lay people to take measures to avoid dementia, although the book could also serve as an introduction for students or health professionals. Despite the book's somewhat sensationalistic title, Defying Dementia is an informative guide to research on dementia treatment and ways to lower risk of developing dementia and to optimize cognitive functioning. The first part of the book is not about defying dementia at all, but is a summary of what dementia is, its diagnosis, and its treatment. Reflecting the author's profession, the discussion of drugs to treat dementia is especially instructive. The case examples—characterized by progressive decline, difficult symptoms, and problems of family members in managing care—are downbeat but realistic. Perhaps the author hopes that the cases will mobilize the reader to take action.
The second part of the book focuses on strategies to lower the risk of developing dementia. Levine is explicit about distinguishing what cannot be controlled—genetic make-up, intelligence and educational attainment, the community in which someone was raised—from what can be controlled. Among factors that can be controlled, he emphasizes physical activity and exercise, cognitive stimulation and socialization, and diet.
The book is well-researched with occasional gaps. For example, although the author twice mentions a possible connection between periodontal disease and dementia, no citation is offered. Anti-psychotic medications are described as ways to control behavioral problems in dementia patients without discussing their limitations and without presenting behavioral interventions as an alternative. This bias, of course, reflects common practice and the need for more interdisciplinary cooperation. In contrast, examples of safe and practical behavioral interventions can be found in several chapters of Geriatric Neuropsychology.
In framing advice to those who do not have dementia, the challenge is how to balance two opposing messages—that we do not know how to stave off Alzheimer's disease, but that things can be done to reduce one's risk. Who would want to discourage people from physical exercise, a heart-healthy diet, or being engaged in the social world—all endorsed by Robert Levine as ways to defy dementia? At the same time, media reports of new discoveries about preventing, reversing, or even halting the progression of Alzheimer's disease tend to be overstated and, according to Richard Taylor, not at all helpful to those diagnosed with the disease. Levine generally achieves an appropriate balance, with his recommendations probably going furthest beyond the evidence in the area of cognitive activities—where he himself admits the lack of hard data about any specific activity—and in the implicit promise contained in his book title.
A new summary of evidence about cognitive interventions is available in a June 2007 special issue of the Journal of Gerontology: Psychological Sciences. Controlled studies of cognitive training lead to the conclusion that healthy, non-demented older adults can benefit from various training programs. Most promising are interventions that include more than just repeated training in mnemonic techniques (Rebok, Carlson, & Langbaum, 2007) or that aim broadly to increase intellectual engagement (Stine-Morrow, Parisi, Morrow, Greene, & Park, 2007). Still, we have to be careful about generalizing from these results to the conclusion that cognitive interventions will affect the risk or course of Alzheimer's disease.
Taylor firmly declares that Alzheimer's disease cannot be prevented. In part, he may be saying that he should not be made responsible for this illness that is gumming up his brain. But his statement should remind scientists and health practitioners to be careful in how they talk about prevention. A useful concept is cognitive reserve, discussed in both Defying Dementia and Geriatric Neuropsychology. According to Scarmeas and Stern (2003), cognitive reserve refers both to the brain's capacity to tolerate pathology, e.g., number of neurons or synapses, and to strategies to compensate for impaired cognition, e.g., through greater efficiency or through developing alternative neural circuits. The former component of cognitive reserve encompasses what Levine calls elements that are beyond one's control. The implication of the theory of cognitive reserve is that many actions now included as "prevention" could usefully be reframed as strategies to assure optimal cognitive functioning given whatever level of brain pathology one may have been dealt. Moreover, it is possible that having greater reserve could delay the time at which an individual reaches the threshold of neural loss at which dementia would be diagnosed (Mortimer, 1995).
Even if rates of dementia are lowered by scientific advances or with massive changes in individual lifestyles, projected numbers of dementia cases create a need for more trained professionals. Geriatric Neuropsychology and Neurocognitive Disorders in Aging are texts to help prepare students and professionals to confront these health care needs. Geriatric Neuropsychology: Assessment and Invention, as the subtitle suggests, is unusual in encompassing not only clinical neuropsychological assessment but also intervention. This volume seems destined to become a major clinical reference book, useful for doctoral and postdoctoral students, practitioners, and researchers. Although edited, inevitably resulting in some redundancies and inconsistencies across chapters, the editors have done a commendable job in creating a unified volume that is nicely introduced by an integrated model of assessment in Chapter 1 and an integrated model of intervention in Chapter 10. In Part I of the book, about assessment, there are sophisticated discussions of issues such as competing concepts to describe conditions between normal cognitive aging and dementia, considerations in differential diagnosis of types of dementia, challenges in establishing and using test norms, functional assessment, and how cultural issues affect assessment and diagnosis.
In Part II of Geriatric Neuropsychology, an array of intervention strategies is presented along with evidence about their effectiveness. The chapter by Linda Clare about cognitive training concludes that cognitive training does not, taken by itself, have sufficient evidence to recommend it as an intervention for those in the early stages of dementia. On the other hand, many successful interventions demonstrate the use of learning theory. What works best is to build on preserved cognitive skills and coping strategies. Use of external aids and adjustments to the environment to create cues or to modify behaviors can be effective. In addition to addressing cognition directly, there are well-documented interventions that target emotional distress and behavioral problems that often accompany dementia. These interventions are described in a chapter by Rebecca Logsdon, Susan McCurry, and Linda Teri. Here too, use of learning theory along with environmental adjustments is key. Group interventions have become popular for early stage dementia patients, where there are issues not only of psychoeducation about dementia, but also issues of grief and loss and finding new roles where the individual with dementia can feel useful. These group therapy approaches are discussed in a chapter by Guy Potter and colleagues. As yet, there are only limited data to address effectiveness. The example provided by Richard Taylor is of interest here. Through writing, use of the internet, and involvement with the Alzheimer's Association, he has found ways to stay engaged, use his skills that are preserved, and compensate for lapses in memory abilities.
Geriatric Neuropsychology concludes with a chapter by Kathleen Hayden and Mary Sano that explains clinical trials, summarizes approved medications for use in Alzheimer's disease and other dementias, suggests what new directions to expect in pharmacological treatment, and gives a summary of the evidence with respect to preventive agents. Clear distinctions are made between use of agents to treat dementia, epidemiological studies about protective factors for dementia, and clinical trials to test putative protective agents. These latter include nutritional supplements, anti-inflammatory drugs, estrogen, and other substances. Potentially, the same agent could appear in all three roles—as a treatment, as a protective factor in epidemiological studies, as an agent in a clinical trial—but the evidence may be divergent. The challenge for scientists is to explicate these differences such that public health implications can be conveyed consistently and unambiguously.
Neurocognitive Disorders of Aging provides a quite different and sensible approach to understanding brain dysfunction in older adults. The book is, appropriately, advertised as an introduction suitable to the undergraduate or graduate level. The text starts with a primer on neuroanatomy, followed by a very instructive description of stroke, which is one of the most common causes of brain dysfunction in older adults. Dementia and Alzheimer's disease are not discussed until Chapter 11, in the final third of the book, after various focal impairments have been explained. Moreover, the description of specific dysfunctions begins with several chapters about language and communication, rather than with memory. For each specific dysfunction, there is a section on methods of assessment and a section about treatment. Methods of assessment are presented so that it is clear how the specific deficit relates to a particular focal neurological impairment. The reader is thus able to gain a broad understanding of how different lesions might manifest themselves in cognition and behavior, including motor control. To a large extent, treatment focuses on exercises, although for memory, compensatory approaches using external aides are also included. Suggestions for treatment are tied to neuropathology but are presented without data from clinical trials. For anyone preparing for a career in speech and language disorders, there is a wealth of information and clinical wisdom.
A few discussions and citations seem a bit dated. For example, mild cognitive impairment (MCI) is not mentioned in the section about the continuum from healthy aging to dementia. The discussion of risk factors for Alzheimer's disease is similarly thin. Combining delirium and depression in one chapter seems to have no particular neurological or pedagogical basis. A guest-authored chapter on successful cognitive and physical aging, by Melissa Tabbarah and Teresa Seeman, gives a nice summary of findings from the MacArthur Foundation Studies of Successful Aging but, understandably, the material is not integrated with the rest of the book. Unaddressed is whether the predictors of successful aging are being represented as ways to prevent the dysfunctions and disorders described in the rest of the book.
In considering either Geriatric Neuropsychology or Neurocognitive Disorders in Aging for use as a textbook, the only complaint is that the trainee who is looking for recommendations about choosing neuropsychological tests and for information about how to obtain copies of tests may be somewhat frustrated.
Gerontologists need handbooks on dementia to inform themselves, textbooks for teaching, and books to recommend to clients and the public. All four of these volumes are welcome additions. Together they raise issues about best ways to present information in a field where the science is rapidly changing and how findings are translated can be consequential.
References
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