Kenneth Rockwood and Chris MacKnight
Pottersfield Press Ltd. 2001-11-09
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.