Clinical Neurology of the Older Adult

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.