Editors: Valentin Fuster MD, PhD, R.Wayne Alexander MD, PhD, Robert A. O'Rourke MD

Reviewed by: Madhuri Reddy, MD
Associate Editor, Geriatrics & Aging

Thirty-five years after Dr. J. Willis Hurst published the first edition of Hurst's The Heart, the 10th edition has been released. The new edition covers the entire spectrum of cardiovascular disease, from basic science and molecular development, to clinical applications and the latest genetic therapies.

From the perspective of a clinician caring for the elderly, there is one particularly useful chapter, entitled "Cardiovascular aging in health and therapeutic considerations in older patients with cardiovascular diseases." It provides detailed descriptions of the anatomic and physiological changes in the normal aging heart, and explores their possible relationships with pathological states. Therapeutic options and evidence-based rationale are given for the most common disease states such as systolic hypertension, valvular disease and coronary syndromes.

Another practical chapter describes practice guidelines in cardiovascular care. It reviews, in straightforward charts and diagrams, guidelines for risk stratification and treatment for everything from blood pressure to cholesterol (in mg/dL rather than SI). Algorithms are given for treatment of chest pain, heart failure, valvular disease and preoperative assessment of cardiac risk.

A particularly timely chapter describes "Cost-effective strategies in cardiology." Costs are initially described from a societal perspective, with background provided on the different types of economic analyses used to study costs, and on cost-effectiveness in prevention, diagnosis and therapy in common areas such as hyperlipidemia, smoking cessation, anti-hypertensive screening and atrial fibrillation. This is a wonderful chapter, supplying practical information to the clinician (and non-health economist) and insight into public policy as it relates to cardiovascular medicine.

There are also a couple of interesting chapters on insurance and legal issues in patients with heart disease. Other chapters explore the effects of mood and anxiety disorders in cardiovascular disease and describe behavioural therapies.

Overall, this substantial text acts as an excellent reference for the non-cardiologist. It reviews common cardiovascular conditions in a clear, well-presented manner and provides a multitude of charts and graphs to display information. Chapters on history and cardiac auscultation will appeal to those clinicians early in their training, whereas chapters on MRI and PET (with superb imaging) and techniques of electrophysiology make wonderful reference for even the experienced clinician.

Kenneth Rockwood and Chris MacKnight
Pottersfield Press Ltd. 2001-11-09
ISBN 1-895900-15-8

Review by: Barry Goldlist

The first page of this book is a statement by the authors concerning potential conflicts of interest they might have. In that same vein, let me declare my conflicts of interest. First, I feel that the issue of dementia is of incredible importance to our aging society and that no network of specialists or memory clinics will be able to handle the problem unless primary care physicians can efficiently manage the usual types of dementia. Secondly, I know the two authors extremely well. Ken Rockwood is an internationally-recognized clinical researcher in the field of dementia, and Chris MacKnight is a bright young star in the field. I am thrilled to say that both are Canadians and practice in Canada (both are on the faculty of Dalhousie Medical School in Halifax).

The target audience for this book is family physicians without special expertise in dementia. What is so unusual about it is that the authors have organized this book with an excellent understanding of the time constraints and resource limitations inherent in modern day primary care.

The initial sections give a brief review of Alzheimer disease (AD) and its staging, as well as descriptions of vascular and other dementias. The thrust throughout this section is very consistent. The authors persuasively argue that the key issue in primary care is to recognize typical AD (and vascular dementia) so that the physician can identify discrepancies in the usual pattern. Thus, the family doctor will know when to refer the patient for diagnosis of less common dementias and when to suspect superimposed illness (delirium). For this reason, the authors stress the importance of staging in AD. If events do not progress as expected, or if there is stage incongruence (some symptoms or signs not appropriate for that stage), the family doctor will be prompted to reassess.

The following chapters, recognizing the inability of a family doctor to spend enormous amounts of time, show how to divide the assessment into several visits. The purpose of visit 1 is to determine if the patient with a memory complaint actually has a memory problem. Visit 2 attempts to answer the question 'Does the patient have dementia?' accurately, by focussing on whether more than memory is impaired. In the text, Rockwood and MacKnight provide all the necessary tools to answer these questions, and make recommendations on the extent of laboratory and radiological investigation. Visit 3 focuses on the exact type of the patient's dementia, and once again this practical text does not pretend to be comprehensive. Rather, it focuses on how the family doctor can be confident and comfortable in diagnosing the common kinds of dementia. In Chapter 4, management plans are outlined and protocols for follow-up are described for visit 5 and on. The book then concludes with sections on pharmacology for both cognition and behaviour. The conclusion has an excellent algorithm that summarizes how the primary care physician will organize the evaluation.

Each chapter is replete with 'clinical pearls' and superb case presentations. I enjoyed these cases because many were inconclusive, and messy, just like those in my own practice. They have been carefully selected and illustrate beautifully the didactic information of that chapter.

My only quibble is with the actual printing style of the book. While the font is generally clear and crisp, I did not enjoy the grey subtitles that are the same size as the subsequent text. As well, many of the tables are not well differentiated from the surrounding text, and the unwary reader might not initially know that she has strayed from the text. These issues are extremely minor and did not distract from my enjoyment of the text.

In summary, I feel this is a superb book. I am generally an "optimistic" reviewer, but I do not think I have ever reviewed a book that has targeted its audience so precisely, and met its stated objectives so well. I am confident that anyone who reads 'Understanding Dementia' will agree that my "conflict of interest" has not impaired my judgement. Any family doctor who sees elderly patients (because they will be seeing dementia even if they do not recognize it!) would benefit from reading this book.

Editors: Frank T. Denton,
Deborah Fretz and Byron G. Spencer
UBC Press, Vancouver, Toronto 2000
ISBN 0-7748-0788-1

Reviewed by: Dr. Goldlist

As a practicing geriatrician for over 20 years, I have always advised my patients (and others) to make sure that when they are old they are healthy and wealthy. I have been shocked over the years to see how often my sage advice has been ignored! Our knowledge about ensuring good physical health in old age is pretty rudimentary: eat properly, do not smoke, exercise regularly and pick long-lived parents. But a satisfying old age is also dependent on economic security. That is the topic of this excellent book, which summarizes a 3-year research program at McMaster University that started in 1995. The contributors are a distinguished group of Canadian investigators, and the book is firmly grounded in data.

Although not claiming to be comprehensive, the book covers many areas, all from a distinctly Canadian perspective. We are given mortality data (available functional data not being as accurate) that argue persuasively that, even if age 65 was once appropriate for defining old age, it is so no longer. The third chapter explains how population demographics are projected, and proves that the anticipated aging of the Canadian population is a robust finding, regardless of what fertility rates and immigration are assumed. I found Chapter 4, in which data and anecdotes about how seniors define independence are presented, both excellent and enlightening. There are several chapters that focus on older women. Once again, they are data driven and outstanding. I will not show my wife the chapter demonstrating that, among older women who live alone, those who have never married are financially much better off. Another chapter outlines the economic disadvantage of unexpected early retirement. Throughout the book it is clear that financial security is a tremendous issue for old age, one for which many Canadian are not adequately prepared.

This book is not meant specifically for physicians, but is a useful source of information for gerontological researchers. It is also of interest to anyone who anticipates growing old.

Rudolph E. Tanzi and Ann B. Parson
281 pages
Perseus Publishing, Cambridge Massachusetts, 2000
ISBN: 0-7382-0195-2

Reviewed by: Dr. Barry Goldlist

Clearly, the topic of Alzheimer disease (AD) is always of interest to a geriatrician such as myself. However, this book has a much wider appeal than simply for those with a particular interest in neurodegenerative disease. The book tells the story of Rudolph Tanzi and his part in the hunt for the genetic basis of Alzheimer disease. Since Tanzi started on the ground floor--in fact, he helped construct the ground floor--the book gives a wonderful overview of the development of molecular genetics as it pertains to AD. The structure of the book is superb, and the prose is clear; the author makes complicated concepts intelligible to the average reader, without ever seeming patronizing. The co-author of the book, Ann B. Parson, is an experienced science journalist, and I suspect her contribution to the book can be found in the elegance of the writing.

Why do I feel this book should have wide appeal, even to a lay audience? In addition to the skilled writing, the book can be read as a thrilling mystery story--albeit with the final mystery as yet unsolved. As well, it serves as a description of the process of medical science, from the inspired hunches of well prepared 'amateurs', to the smooth functioning of large academic laboratories, and further to the involvement of huge multi-national pharmaceutical companies and their indispensable role in drug development. Finally, it makes science 'personal' by giving glimpses of the foremost scientists in the field, describing their alliances and feuds, and their reactions to success and failure.

It was this last facet of the book that I found most interesting. The shifting alliances among the investigators (including break-ups within successful labs) remind me of Chaim Weizman's aphorism, 'great powers have no permanent friends, only permanent interests.' Tanzi himself seems like a very appealing individual, with wide interests (especially music) outside of science. He appears to be one of those rare individuals who is able to take his work seriously, without being too serious about himself. In fact, there are no real villains in this book. Tanzi himself hints at a hypothesis that I suspect might be true. The very nature of scientific breakthrough is predicated on competition. One can compare it to putting deadlines on labour negotiations; without them no serious bargaining ever occurs. Similarly, the thought that someone else might publish the 'breakthrough' article is a tremendous stimulus for an ambitious researcher. The big prize in this story was the discovery of the presenilin 1 gene on chromosome 14, the commonest cause of early-onset AD. The intense pressure, media scrutiny and cut-throat competition are clearly, and thrillingly detailed. For a University of Toronto faculty member such as myself, the result of the thrilling race was truly satisfying--the winner was Peter St George-Hyslop, the director of the Centre for Neurodegenerative Diseases at the University of Toronto.

As a preface to each chapter, Tanzi and Parson tell a bit of the story of the Noonan family, a large, Boston area kindred afflicted with early onset AD. This reminds the reader of the urgency that researchers feel in their race to understand the disease. One of the clear heroes in this book is the pathologist George Glenner who first characterized the nature of cerebral amyloid, a tremendous impetus for further research. He and his second wife established day centres to help care for victims of AD. Glenner was continually re-energized by his clinical work in those centres, once again providing a clear reminder that the passion shared by these researchers is not merely intellectual. It is worth reading this book to get a glimpse of that passion.

Edited by Thomas T. Yoshkawa & Dean C. Norman
Marcel Dekker, New York 2000
ISBN 0-8247-0345-6

Reviewed by Barry Goldlist

This book is an effort by multiple authors. Of the 43 contributors, all are from the United States, and 29 are from California. As a result, the approach is distinctly American. Despite this fact, it is an excellent work. The editors have imposed a structured approach on each chapter, making for an easier read, and there is less repetition than is found in most multi-authored texts. Even more impressively, authors of individual chapters have actually focused their comments on truly geriatric issues, rather than merely repeating the contents of more general texts. The result is that the book is not comprehensive; nor is it meant to be. It should be considered an accompaniment to more comprehensive textbooks on emergency and critical care.

The text is divided into four sections: principles of geriatric critical care, surgical emergencies, medical emergencies, and special issues of aging. The principles section is quite solid, and has a superb chapter on acute and critical nursing care, which may be particularly useful for non-geriatricians. It is easy to argue that specialized geriatric nursing is in fact more important than specialized geriatric medical care. I suspect that the chapter on surgical emergencies would be most useful for non-surgeons involved in the care of these patients. I found the discussion of hip fracture particularly clear and helpful. The chapter on emergency anaesthesia is well written but there are a few minor quibbles. For example, the author discusses the unreliable blood levels of meperidine when the drug is given intramuscularly, but does not even mention that meperidine is a poor choice of narcotic for the elderly, and should rarely, if ever, be prescribed in that group.

The medical section is quite strong. The chapter on cardiac emergencies has a superb segment on the atypical presentation of acute myocardial infarction in the elderly. The neurology chapter is also very useful, but should have provided some hints on the non-pharmacological management of the symptoms of delirium, as well as a more detailed description of the pharmacological management of this syndrome. This is poorly managed by many physicians, and is worthy of more detail.

The final section on special issues of aging covers vision, hyper- and hypothermia, and diagnoses of abuse and neglect. The highlight of this section is Robert Palmer's chapter entitled 'Acute Hospital Care: Future Directions'. For those of us who have repeatedly been a witness to the unnecessary functional decline that occurs in hospitalized elderly patients, the description and the rationale for ACE (acute care of the elderly) units are very encouraging.

In summary this is an excellent book. It will appeal most to physicians who work in the emergency department or care for sick elderly patients on hospital wards.

EVIDENCE-BASED MEDICINE
How to Practice & Teach EBM, 2nd Edition

David L. Sackett, Sharon E. Straus,
W. Scott Richardson,
William Rosenberg, R. Brian Haynes
Churchill Livingstone 2000
Edinburgh, London, New York, Philadelphia, St. Louis, Sydney, Toronto
ISBN 0 443 06240 4

Reviewed by Barry Goldlist

This is a new edition of the classic text on evidence-based medicine, first published in 1997 by Sackett and his colleagues. The question for the prudent (i.e. penny wise) physician is this: should I buy this book if I already own the wonderful first edition? To answer this question I pulled my first edition off the shelf, and started comparing. My first edition is from the United Kingdom, so results of your own comparison test might vary slightly.

The new edition is wider, but is not as thick as its predecessor. This results in much better "page appeal" with a less cluttered look. Despite this, it still fits easily into a standard lab coat pocket, an important point for trainees in particular. A new author has also been added, Sharon E. Straus, a Canadian Geriatrician and expert on evidence-based medicine. The "cheat" cards tucked into a slot on the back cover are organized in a more logical manner than they were in the first edition, and are larger and more legible and of better quality. Some cards have been much improved and have even been expanded to two cards. New cards on "Screening and Case-finding" and "Useful URLs on the Internet" have been added. The one quibble with the cards is that the chart of the likelihood ratio nomogram is much smaller than the chart in the earlier edition, and is the only card in the new edition which is harder to read than its predecessor.

The new edition has a CD-ROM tucked into the front cover. The entire contents of the book are contained on the CD-ROM, which is very easy to set up and use. As well, it has clinical examples, critical appraisals, and background papers from 14 other health disciplines. The section on EBM in Geriatrics is written by Dr. Straus and, as expected, is superb. As well, the CD-ROM has extended descriptions and sample web pages of many of the current evidence sources regularly consulted by the authors. The book even has a website (www.library.utoronto.ca/medicine/ebm/>), where updates to the text, links to other evidence-based sites, and communication to the authors can occur. This should suffice until the 3rd edition is published!

However, a text of this kind is likely to be most frequently used in a more traditional manner. I use it to review particular aspects of EBM, or when I am reading an article and want to critically appraise it. For these functions, the cards and the written text are most useful. In this edition the introduction is shorter and, to my view, more positive and effective. The chapters are broken down into more manageable sections (5 in the old text, 9 in the new) and are extensively updated. The section on teaching methods is new and helpful for those in academic medicine, and the section on evaluation is helpful to all physicians.

In summary, an already excellent text has been significantly revised and upgraded. The new edition is easier to read and easier to use. The addition of a CD-ROM is also helpful. You will not regret buying the 2nd edition.

Reviewed by: Barry Goldlist

The Merck Manual of Geriatrics, 3rd Edition
Published by Merck Research Laboratories
Whitehouse Station, NJ 2000

Almost a decade ago, I received a copy of the first edition of the Merck Manual of Geriatrics for review, and decided to take it on ward rounds with my residents. Rather than my answering their patient related questions, we looked things up in the manual and were all favourably impressed by the results. It was easy to use, and provided rapid access to succinct and helpful information. Needless to say, my review of the volume was very favourable. I was still able to give my residents good evaluations because they said they still preferred my answers. Smart residents.

The third edition of the manual is much larger, and significantly heavier than was that original volume. It has gone from 1267 pages in length to 1507 pages, and the pages are larger. It would not accompany anybody on ward rounds. However, with the added weight comes more information. It is still very easy to extract information in order to answer specific clinical questions because of the excellent index, and the usual Merck technique of making the chapter headings visible via 'thumb holes'. Not only does it provide excellent information on specific geriatric issues such as falls, incontinence, and interdisciplinary teams, it also provides good coverage of important issues in general internal medicine that relate to the elderly.

Unlike standard textbooks of geriatric medicine, the geriatric giants (incontinence, falls, etc.) are not grouped together, but rather are addressed in the appropriate system section. However, this method of indexing does not cause any problems. As in previous editions, many charts are used to transmit information in a very efficient manner.

Who should buy this textbook? It is not intended to be a comprehensive textbook of geriatrics, and the lack of references probably makes it inappropriate for purchase by those who specialize in geriatrics. However, the ease of use, and the wide variety of useful information it contains, would make it a useful text for family physicians or internists who treat elderly patients in their practices. It would also be a useful textbook for trainees in those disciplines. I highly recommend it.

JE Morley, L van den Berg, editors
Humana Press, Totowa NJ 2000
ISBN 0-89603-756-8.

Reviewed by: Barry Goldlist, MD, FRCPC, FACP

This textbook is an American multi-authored text. As is usual in such books, there is some qualitative variability from chapter to chapter. Unlike some American texts, it does feature some contributors who do not work in the USA. In fact, two Canadian geriatricians wrote the chapter on Diabetes in the Elderly, Graydon Menelly from the University of British Columbia and Daniel Tessier from the University of Sherbrooke.

The introduction, on the Biological Theories of Aging, is very cursory, but does provide a reasonable overview for the neophyte. There are relatively few references from 1995 on for this chapter, but it is probably adequate for this type of text. The chapter on age-related decline, entitled "Tithonusism" after the character in Greek mythology, is well written and provocative, although I doubt whether the term "Tithonusism" will ever catch on. It is just too difficult to pronounce!

Of all the chapters, the one by John Morley on "Testosterone" is by far the best. There are three reasons for this: First, Morley offers a wonderful historical perspective on research in the field. Secondly, the evidence on the role of testosterone in aging is very clearly presented, and any management suggestions are clearly evidence based. Finally, the writing style is wonderfully accessible. I felt as though I was having a conversation with an expert, not reading an academic text. Most of the chapters do not measure up to this one, but there are still some excellent sections. The chapter on diabetes is very thorough and academic, and the management options are clearly spelled out. Some chapters seem a bit out of place, e.g., gynecomastia, and others simply describe a disease common in the elderly such as Paget's Disease of Bone. I suspect that this chapter would be no different if it appeared in a standard textbook on endocrinology.

On the whole, I feel this is a useful text. Its most likely audience would be specialists in geriatrics and endocrinologists with a particular interest in aging. It would also be a worthwhile text for institutional libraries to obtain.

Elegy for Iris
By John Bayley (Picador USA, 1999)
275 pages

Iris and her Friends-A Memoir of Memory and Desire
By John Bayley (Norton, 2000)
275 pages

Reviewed by: Dr. Michael J. Taylor

The staggeringly high incidence of Alzheimer's disease (AD)--an estimated 5-10% amongst the over 65 age group--is well known to clinicians working within all fields of adult medicine. The incidence of Alzheimer's and other forms of dementia, in those over 85, is estimated to be as high as 47%. With shifting demographics creating a rapidly expanding cohort of patients over 65 years of age, the absolute numbers of those suffering from AD will make the collective tragedy of this devastating disease more apparent. In dealing with the myriad medical, behavioural and psychosocial problems stemming from the increase in the number of Alzheimer's patients, it may become increasingly difficult for clinicians, particularly those working in long-term care facilities, to recognize the devastating impact that dementia can have on both patients and their loved ones. It may also become more difficult to stay aware of the fact that the patient's individuality is lost within the common symptoms of advanced dementia. In two recent books about his wife, Iris Murdoch, also an Alzheimer's disease patient, the writer and literary critic John Bayley elegantly describes the full impact of this devastating disease; he manages to remind the reader that love and devotion can be unfailingly strong even in the face of adversity. The book also serves as a powerful reminder of the individual tragedy of AD.

Born in Dublin in 1919, Iris Murdoch began her career as a fellow and tutor in Philosophy at Oxford. She went on to obtain international acclaim as a writer of philosophy, and of plays and works of fiction that included The Sea, The Sea, which won the prestigious Booker Prize for literature in 1978. The first sign of Iris' Alzheimer's disease appeared in 1994 while she was at a literary conference at the University of the Negev in Israel. This episode is painfully recalled in John Bayley's first novel dealing with his wife's disease, Elegy for Iris. Published in 1999, the New York Times' best-selling Elegy for Iris met with a great deal of both critical and popular success, and justifiably so. The book is a moving and honest portrayal of Bayley's daily struggle in caring for his wife, accompanied by touching accounts of the couple's courtship, marriage, and early life together. Throughout the book, Bayley effectively juxtaposes episodes from his present with episodes from the past. Perhaps most memorable is the account of Bayley swimming with his wife in their earlier days in a small nook that was part of a river near their home. The reader is presented with a tranquil scene of two young lovers finding refreshment in a quietly flowing river surrounded by lush vegetation on a hot summer day. Abruptly, this scene shifts to a more current one that is almost pitiable but ultimately rather moving. This time we find Bayley trying to undress his wife, who is now in an advanced stage of her disease, and coaxing her into the river so that they may continue the ritual swim that had, in the past, been so important to them.

Elegy for Iris is so full of frank and honest observations about Iris Murdoch's disease that it will sound familiar to anyone having had contact with Alzheimer's patients. Surprisingly, the tone throughout much of the book is rather positive, although there is an underlying melancholy. This melancholy is apparent as Bayley discusses his life with Iris prior to the onset of her disease, meditates on the complexities of their relationship, and describes the dutiful, at times seemingly heroic, way in which he cares for his ailing wife. It is a tone that changes rather noticeably in Bayley's follow-up to Elegy for Iris titled Iris and her Friends. Those expecting more of the same as in Elegy for Iris will be greatly surprised by this much darker book, that continues where Elegy for Iris left off, with an account of Bayley's struggle to care for his wife as her disease progresses. Though Bayley's technique of changing rapidly between past and present remains easily recognizable, in Iris and her Friends, Bayley has lost the gentle and almost passive tone he previously used when describing the experience of caring for his wife. In place of this tone, the voice of Iris and her Friends expresses Bayley's frustration and despair in dealing with the daily struggles of being a caregiver. It is a voice that is at times shocking. For instance, when Bayley loses his patience with his now silent wife while having difficulty dressing her, he finds himself suppressing a desire to actually strike her, staring at her with an ironic smile and saying "do you know how much I hate you?"

The "friends" of the title is not a reference to Iris' companions but is used by Bayley as a somewhat elusive metaphor to describe the silence and passivity that "visit" his wife as her disease progresses. It is these "visitations" that allow Bayley to explore his own memories as his wife's memory continues to decline. It is in these recollections, full of engaging anecdotes, that the reader may find respite from the, often upsetting, accounts of Bayley's situation. It soon becomes apparent that living within his own memories is Bayley's method of coping with the tragedy surrounding him. What the reader of both books cannot fail to notice is that while in Elegy for Iris Bayley's reminiscences were concerned with his life with Iris, in Iris and her Friends, Iris is completely absent from any account of his early life. It is as though Bayley is suggesting that he himself must forget his wife in order to escape from the pain of his current situation. However as the book draws to a close, Bayley's love and dependence on his wife are clearly reaffirmed through a touching description of his fear and anxiety of losing Iris as her condition deteriorates to the point where she must be transferred to a nursing home. What follows is a heart-breaking but beautifully rendered account of Iris' final days.

Despite their short length, neither Elegy for Iris nor Iris and her Friends make for light reading. In both books, Bayley brilliantly uses his skills as a writer to lead the reader on an emotional journey, throughout which the most intimate and personal details of his life before and after his marriage to Iris, and during the long course of her illness, are divulged in a fluid and literary style. Of course it is impossible for Iris Murdoch not to lose some measure of dignity, given that both books focus so heavily on her in an advanced stage of dementia. This is particularly true of the latter of the two novels. It is in the first novel that Bayley's balanced juxtaposition of the past with the present serves to remind the reader that his ailing wife was a dynamic, vibrant and intellectual woman before the onset of her disease.

Though intended for a general audience, caregivers of patients with Alzheimer's disease may find solace in Bayley's honest portrayal of his own experiences. In the end, Bayley has provided an unforgettable account of the full impact of Alzheimer's disease, and a reminder to anyone encountering patients with this disease that behind what Bayley refers to as the "mask" of Alzheimer's disease are unique individuals who lived, loved and were loved in return. Certainly, no one reading Bayley's two courageous accounts of his own experiences, can fail to notice that the tragedy of Alzheimer's disease affects both patients and their loved ones. Indeed, both books may offer a great deal to clinicians who, in encountering this disease on a daily basis, may forget that Alzheimer's is a tragedy which is unique to every individual afflicted with it.

Oxford Textbook of Medicine 2nd Edition

Editors :J. Grimley Evans, T. Franklin Williams, R. Lynn Beattie, J-P. Michel, G.K. Wilcock
Oxford University Press, Toronto, 2000

Reviewed by: Shabbir M.H. Alibhai, MD, FRCP(C)

Geriatric textbooks come in several varieties. Some focus on specific content areas and are both comprehensive and detailed. Others cover pertinent areas of geriatrics in a portable overview fashion. A third group--which includes the Oxford Textbook of Medicine--is comprised of stand-alone reference texts that combine the best of both broad-based coverage and comprehensiveness, bringing together the art and science of medicine in one heavy tome. This is an onerous task in which the Oxford Textbook of Medicine succeeds well in some areas but not so well in others.

As the focus of my review of this large volume (over 1,200 pages), I chose, in addition to doing a general overview of the 27 sections of this guide, to examine several subject areas. These areas are representative of well-known evidence-based areas of geriatrics (anticoagulation in atrial fibrillation), of emerging fields that show some level I evidence but that lack in consensus (cognitive enhancing therapy in dementia) and finally, of topics that elicit much opinion, but which are based on little data (pharmacological treatment of delirium).

To begin with, this reference is written by numerous distinguished contributors from various fields of clinical geriatrics and gerontology, basic science, ethics, and research. The editors and authors are an internationally diverse group that brings together ideas in modern geriatrics from several continents. The text and tables are nicely formatted and easy to read, although the almost absolute lack of colour, and limited illustrations, make it visually challenging at times. There are very few annoying typographical errors. Chapters are organized logically, although in the organ-based medicine sections it would have been nice to have, consistently, an introductory chapter on the physiology of aging of each organ system. The index is also easy to use although a bit sparse at times (e.g. B12 is only listed under cobalamin and vitamin B12, not B12).

In its capacity as a comprehensive overview of geriatrics, this textbook does well in offering the reader some nice chapters about the demographics of aging, and about aging in developing countries. There is welcome coverage of a number of other miscellaneous topics like the concepts of frailty and "failure to thrive", and the roles of geriatric day hospitals and stroke units. Unfortunately, some topics (e.g., fecal incontinence) which are not well covered in traditional texts and review articles, are covered sparsely in this book as well. From my own perspective, the very thin chapter on cancer and aging is embarrassing. The section on ethics mentions nothing about religiosity and the impact of traditional beliefs on many patients' and caregivers' ethical positions with respect to their medical treatment.

In terms of evidence-based medicine, the offerings vary in quality. The editors have tried very hard to cover the subject matter succinctly, but numerous times throughout the book the material ends up being too terse. The anticoagulation literature in chronic atrial fibrillation, for example, is summarized well in text and tabular form, but a short paragraph on paroxysmal atrial fibrillation management gives questionable recommendations with no references to any literature. Several pivotal cardiovascular and diabetic clinical trials are not mentioned at all, and the controversies regarding the estimation of creatinine clearance in the elderly are largely ignored. Despite the completion of over twenty large randomized trials testing cognitive enhancing therapy in dementia, only a few paragraphs struggle to summarize this challenging body of information. Conversely, in delirium management, the writer justly discusses the limited amount of evidence which exists to guide treatment and goes on to offer what amount to some clinical management pearls given the paucity of controlled trials.

Two final points deserve mention: First, there are many sections where practical flow-charts or algorithms could have been added which would have aided clinical decision-making and clarified the subject matter. Second, there is a nice little collection of paper instruments and scales in the useful information chapter, although it would have been nice to get a standardized guide to scoring the Folstein MMSE along with the actual instrument.

At the end of the day, there is enough information from a tremendous variety of sources and experts in this volume to make it a welcome addition to the library of a physician with a strong interest in geriatrics. However, it needs to be spruced up to compete with more sophisticated electronic/ online offerings and to appeal to physicians looking for better and clearer science. A good book, but temper your expectations.