Dementia, Second Edition

Dementia, Second Edition


Editors: O'Brien J, Ames D, Burns A.
Oxford University Press, 2000.

Reviewed by: Christian Bocti, MD, FRCPC, Cognitive Neurology Unit, Sunnybrook and Women's College Health Sciences Centre, Toronto, ON.

There has been a tremendous increase in the pace of discoveries related to the dementias in the last two decades. For a clinician, it is difficult to keep up with all this new information. Few textbooks on the topic attempt to integrate all fields of knowledge in a comprehensive manner--from basic neurochemistry and neurobiology to clinical approach and neuropsychology, and from pharmacotherapeutic strategies to multidisciplinary management and community services for patients with dementia. Although there are good textbooks available that cover some of these individual aspects, Dementia, Second Edition is the most ambitious textbook presently available, with the many advantages and few drawbacks that such a vast undertaking implies.

The book has 70 chapters (17 more than the first edition) organised in seven parts, which provides a user-friendly structure. There are 133 contributors, mostly from the U.K. but also from continental Europe, North America and Australia. The editors have accomplished a monumental task in coordinating the work of this large number of authors.

General aspects of dementia are reviewed in the first part, which constitutes a full third of this book. Diagnostic criteria for Alzheimer disease (AD), vascular dementia (VaD) and dementia with Lewy bodies (DLB) are discussed, as well as related concepts such as age-associated cognitive decline (AACD). However, the absence of consensus criteria for frontotemporal dementia (FTD) in this section is surprising (they are presented in a later chapter). Clinical aspects of dementia are then presented, including a brief overview of neuropsychology and a more elaborate chapter on neuropsychiatric features. Reflecting the increasing importance of neuroimaging in the differential diagnosis of the dementias, there is a series of chapters that provides a good synthesis of neuroimaging techniques currently in clinical use (CT, SPECT and MRI).

Following, there is an elaborate section on familial, social, cultural and economical aspects of dementia care, as well as a review of services for patients with dementia available in many parts of the world, including developing nations. Most notable are the chapters on sexuality and dementia, and on ethical and legal aspects of dementia care--seldom-discussed issues that can have significant impact on the quality of life of patients.

The second part of the book provides a detailed review of Alzheimer disease, starting with definitions, risk factors and epidemiology. The natural history is described, and the neurobiology section includes very good chapters on the cholinergic system and the neuropathology of AD. Disturbances in other neurotransmitter systems are exposed more succinctly, and genetic factors and even animal models of AD are reviewed in some detail. Therapeutic strategies are presented next, and the use of cholinergic drugs are put in a humbling historical perspective. There also is an extensive review of treatments for behavioural and psychological symptoms, both pharmacological and psychosocial. The chapter on pharmacological approaches provides a well-structured and rational clinical methodology to treating behavioural disorders, with a remarkably comprehensive review of published studies.

The third, fourth and fifth parts of the book cover VaD, DLB and FTD, respectively; all these chapters are written by leaders in the field and provide clear, concise overviews of each entity. Controversial issues, including the importance of leukoaraiosis in cognitive impairment are well discussed. The section on FTD provides good perspective on the different sub-syndromes and clarifies conflicting terminology used by various authors in the literature.

The sixth part briefly reviews neuropsychiatric disorders associated with dementia. The prototypical disorder, Huntington's disease, is well synthesized. There is very little elaboration, however, on dementia in Parkinson's disease. Other chapters provide overviews of cognitive dysfunction in schizophrenia, depression and alcoholism. The inclusion of these chapters in a textbook on dementia is a welcome step forward to a unified conceptualisation of brain-behaviour relationships. The last part provides a brief overview of Creutzfeldt-Jakob disease, HIV-associated dementia and other uncommon dementias.

Overall, this is a comprehensive, authoritative and accessible textbook that anyone involved in the care of patients with dementia will find very useful. It goes well beyond what is found in any other work on dementia, and it presents a good balance of basic science and clinical and psychosocial aspects. In such a wide-ranging text, certain topics are inevitably presented in less detail than others, but globally, this is an excellent textbook. In the decades to come, dementia will become one of the major challenges facing our society and, despite exciting recent developments, there is still much work to be done to meet these challenges.

Review of “Management of Dementia”

Review of “Management of Dementia”


by Simon Lovestone and Serge Gauthier, Martin Dunitz, 2001.

Reviewed by Chris MacKnight, MD, MSc, FRCPC, Assistant Professor, Dalhousie University.

When I was asked to review this book I thought, Not another guide to dementia! I was right--this isn't yet another guide to dementia. It is an excellent, helpful and practical book, and one that I greatly enjoyed.

The authors, Drs. Serge Gauthier and Simon Lovestone, are experienced and respected experts in dementia, and they have distilled that experience into 150 easily read and understood pages. Being from both sides of the Atlantic, they bring a nice trans-continental perspective to the book, and their respect for their patients is evident on every page.

The authors don't get bogged down in the minutiae of pathophysiology and pharmacology, but rather present what a practitioner needs to know to get the job done. They begin with a chapter on the newly diagnosed patient, and follow with chapters on common behavioural problems (including one on sleep), treatment of the cognitive symptoms, the possibility of disease modification and, finally, a chapter on long-term care, including the design of the facility.

There are a number of excellent features in this book. The end section contains many instruments commonly used in assessing and following patients with dementia, complete with guides for their use. I particularly enjoyed the cases, scattered throughout the text, that aptly illustrated the management issues and were very real-life. The references at the end of each chapter are both comprehensive and current.

I highly recommend this book to trainees and clinicians (both physicians and non-physicians) who see patients with dementia. Most nursing homes, if not every nursing home ward, should have a copy on hand. Even a specialist is likely to learn something from these pages. Unlike so many books I see, I believe I'll actually use this one.

Alzheimer’s Disease and Related Disorders Annual 2001

Alzheimer’s Disease and Related Disorders Annual 2001


Editors: Gauthier S, Cummings JL

Reviewed by: Dr. Barry Goldlist, Editor in Chief, Geriatrics & Aging.

As is my usual practice when reviewing multi-authored textbooks, I immediately went to the list of contributors to see how representative they were of the broad community of experts. In this book, only two of the contributors are from countries other than the United States. One of these, Dr. Serge Gauthier, the eminent Canadian neuroscientist, also acts as an editor. Despite this relative imbalance, the book is excellent and of value to any physician with an interest in Alzheimer disease. Specialists and researchers will particularly enjoy the cutting-edge scientific chapters, including one on amyloid processing by Dr. Greg Cole, and Dr. Gauthier's thoughtful perspective on the past failures and future prospects of the use of muscarinic agonists in Alzheimer disease. Any physician, whether primary care provider or specialist, could benefit from the chapters on depression in dementia, the use of antipsychotic drugs in dementia and the management of late stage dementia. I was particularly impressed by the scientific rigour of the chapter on assessing competency for treatment consent capacity and financial capacity by Marson and Briggs.

With any such text, the lag between writing the chapter and publication means that the latest information cannot always be included. The same week that I reviewed this book, for example, I read an article in the Archives of Neurology on increased B-secretase activity in the Alzheimer disease brain that potentially contradicted some of the assumptions about disease pathogenesis in the book's first chapter. Although I enjoyed Professor Schelten's scholarly review of neuroimaging in the evaluation of dementia, I am not sure there is Level 1 evidence for his assertion that one MRI examination during the course of a dementia evaluation can hardly be judged to be optional any more.

Despite these minor quibbles, this is an excellent book that can be profitably read by any physician who cares for patients with dementia, particularly of the Alzheimer type.

Stroke Prevention Book

Stroke Prevention Book


Editors: Norris JW, Hachinski V
Oxford University Press, 2001
ISBN 0-19-513382-X

Reviewed by: Dr. Barry Goldlist,
Editor in Chief, Geriatrics & Aging.

The most common cause of death in elderly people is cardiac disease, and arthritis is the most common cause of disability. However, in my experience, elderly patients fear stroke or dementia more than they do either of these, and with good reason. The consequences of stroke are devastating, and evidence from controlled trials of educational interventions in atrial fibrillation suggests that patients are eager to do anything that will reduce their risk of stroke. Yet, in developed countries only about 20% of people with hypertension (the most common risk factor for stroke) have their disorder diagnosed and effectively treated. Similar statistics are seen for other risk factors such as atrial fibrillation. Therefore, there is no doubt that continuing efforts in stroke prevention are required, which is the focus of this superb book.

The two editors are both Canadians, and the contributors come from Canada, Great Britain, the United States, continental Europe, Israel and Australia. The inclusion of a contributor from the World Health Organization ensures that the issue of stroke prevention in developing countries is not ignored.

The text is divided into three parts: Primary Prevention; Secondary Prevention; and Prevention: Policy and Practice. The emphasis is on an evidence-based approach. However, the style of each chapter (presumably the influence of the editors) is quite accessible to all readers because the technical terms are clearly defined. This makes the evidence easier to understand for the reader who is not an expert in critical appraisal, without sounding condescending. The list of references for each chapter is voluminous, and considering the publication delay, surprisingly up-to-date (the chapter on carotid angioplasty and stenting includes a reference from the year 2000). The introduction and epilogue by the editors are superb, the former providing a clear outline of the important information on stroke prevention, and the epilogue outlining difficulties in implementing proven strategies as well as future directions.

This book is a 'must read' for those with a particular interest in stroke prevention, and certainly worth having on the bookcase for reference. I think it is also a very useful text for primary care physicians who see older patients. Its careful presentation of the evidence will allow practising physicians to transmit to their patients the type of information that might convince them to try to prevent stroke. Any physician dealing with older patients would benefit, at a minimum, from reading the prologue and the epilogue to this outstanding text.

‘Of a Certain Age': Wisdom Through the Eyes of Some Fascinating Old People

‘Of a Certain Age': Wisdom Through the Eyes of Some Fascinating Old People


A Mark Clarfield, MD, FCFP, FRCPC

As a geriatrician, I was initially put off by the idea of a book full of interviews with famous people&emdash;just because they had attained "a certain age."

But I was wrong.

"Of a Certain Age" by Naim Attallah (Quartet Books, 1992) is well worth the read. The 14 people featured all have had fascinating pasts. They are now quite old (average age 70) and are just as--perhaps more--interesting for having aged so well.

Mostly Bruits, they represent primarily the English uppercrust--a group once described by a wag as "a bunch of crumbs held together by dough."

And some are indeed crumbs--Clause von Bulow and Lady Diana Mosely are two excellent examples. Many are wealthy, but all are worth the listen. There are professors, judges, writers, publishers and sophisticated hangers-on--all expertly interviewed by the British writer and publisher Naim Attallah.

I am not the kind of Jewish reader who divides up members of humanity depending on their attitudes towards my ethnic group. However, in this book it is difficult not to be struck by how these old grandees self-differentiate so clearly into two groups: anti- and philo-Semitic.

At one end of the spectrum stands Diana Mosely, one of the celebrated Mitford girls and the wife of Oswald Mosely, leader of the wartime British Union of Fascists. Today, she lives a quiet, unrepentant life in southern France. Her interview really is a bit awe-inspiring. In it, Lady Diana speaks in such a matter-of-fact manner about her close relations with things Nazi.

For example, relating to her friendship with Hitler. "Unity (Diana's sister) loved and adored him, thought him utter perfection. I never felt like that about him but I did admire him very much for what he had done."

Standing in stark contrast is the Irish politician, writer and editor, Conor Cruise O'Brien.

He is so unabashedly on the side of the Jews: "...[My] degree of sympathy for Israel is based on the realization that Israel is the result of horrendously extreme conditions ... it's an emotional issue with me."

A more "balanced" view is noted by many of those interviewed.

For example, Lord Deedes, an eminent Member of Parliament and publisher, in describing his father's views:

"He had what you might call the Edwardian, old Eton conscience, and I look back on him as a very respected Christian socialist. He was left of centre for what might be described as inner reasons rather than ideology.

"There was one period, for example, when he bought every book he could lay his hands on about Mussolini. There was an endearing enthusiasm about my father's political beliefs and in the early stages he even thought Hitler might do Germany a bit of good."

Another experience, which so many of these famous oldsters seem to have in common, was that of an unhappy childhood and/or a fearful disdain for their parents. Return for a moment to Lady Mosely, not unlike many children of her time and class: "In a way, the person who meant most to me ... was my nanny. I loved her far more than I did my parents.."

[Far more bizarre experiences seemed to have "dogged" young Diana. In answer to a question relating to her father who on occasion would chase the children with the family canine: "I don't think that he was nearly as eccentric as people imagine. You see, he had a bloodhound, and it was rather fun to hunt with him. And we children were there, available…"

She goes on to reassure us that "he didn't hunt us very often... and in any case the bloodhound died."]

A less bizarre, but equally characteristic description of the childhood suffered by so many of the upper class comes from Lord Deedes. He is ashamed "to this day" that his relationship with his own son did not differ significantly from the cold and distant rapport Lord Deedes had with his own father.

"Frankly I was neglectful and I treated my children as my father treated me." And so typical of his generation and class: "...of course, there were nurses and governesses to look after them."

The oh-so-Anglo temperament of these old-timers is much in evidence. Their command of the Queen's English is one of the delights of the book. (And keep in mind that these are merely interviews.) For example, take Lord Deedes once again. In describing a pessimistic view of mankind, he characterizes our species as "being born to trouble as the sparks fly upwards."

There are also many examples of the classic British use of understatement. One of those interviewed, by any estimate a brilliant and supremely accomplished man, is asked a question about his weaknesses. The response: "Every now and again, I get mildly alarmed at the extent to which someone of my rather limited intellectual capacity has succeeded in doing certain things."

The interviewees in the book are all old people and surprisingly, a few have some interesting things to say about aging. One elderly lady talks about a fear greater than that of dying itself: her concerns relating to the manner of her death.

"I'd like to be somebody with a weak heart and then I could simply have a heart attack. But alas, it won't be like that."

Publisher John Murray is asked if he is more or less certain of his opinions as he ages. He responds, "Less sure" and goes on to offer a beautiful quote by Goethe on the subject:

"To be uncertain is uncomfortable, to be certain is ridiculous."

He offers another tasty little quote on the subject of aging: "Man is not old when his teeth decay. Man is not old when his hair turns grey. But man is approaching his last long sleep when his mind makes appointments his body cannot keep."

On the question of the possibility of an afterlife, one that I am sure becomes more pressing with age, Lord Shawcross (chief British prosecutor at the Nuremberg trials) offers the following delightful response:

"It may be that as I get nearer the end [he was 90 at the time of the interview], I become more hopeful that the end will not be final, that there might be something beyond it. But it doesn't absorb much of my thinking even now. All I can say is that I have a little hope that I may meet 'round the corner' those who have preceded me."

The same Lord Shawcross goes on to confirm my non-clinical impression that mourning for a beloved spouse often goes on much longer than is commonly supposed, even among those who are well adjusted:

"My enthusiasm for life did rather come to an end with the death of my second wife, which did come as a terrible shock to me."

And, in response to whether he believes he will ever see her again: "I hope I may. I carry in my pocketbook, even today, something that one sees quoted much more often in memorial services: 'Death is nothing at all. I have only slipped away into the next room. I am I and you are you. What we were to each other we are still. Call me by my familiar name.'

Not surprisingly, given the age of those interviewed, some will have had some interesting childhood memories of people long dead, and places inexorably changed. A particularly evocative example relates to John Murray (the sixth in a line of namesake publishers).

His grandfather (John Murray IV) was ill and young John was a schoolboy home on holiday. Grandad mentioned that a distinguished author was coming to visit.

John IV to John VI: "I think Sir Arthur Conan Doyle is calling today. Will you be kind to him? I hope he may be bringing another typescript."

Conan Doyle did, in fact, come that day, to deliver the very last volume of the Sherlock Holmes stories, and, "I was so staggered by this distinguished man's courtesy to a young whippersnapper like me that I thought: if this is an author, let me spend my life with authors."

And he did.

Also on the issue of aging, we read one of the funniest lines in the book. Lord Soper is quoted as stating that the continued existence of the House of Lords has, among other things, reaffirmed his belief in life after death.

The question for Canadian readers, of course, is whether milord's comments are relevant to our own Upper House.

One of the most poignant expressions, also by Lord Soper, happens to be contained in the last two sentences of the book. In answer to whether he had any regrets, his Lordship responds: "An infinite number. At my age one's sense of failure in the past is an interesting and solemnizing experience. You haven't much time in which to put things right. Which makes me say better prayers than I used to."

This book is a lovely read. Especially if you are interested in the wisdom (and sometimes cant) of an extraordinary stable of old people who aged along with the past century.

Dr. Clarfield, MD, FRCSC, is the Chief of Geriatrics, Soroka Hospital Centre, a Professor and Sidonie Hecht Chair of Gerontology, Faculty of Health Sciences at Ben Gurion University of the Negev in Beersheva, Israel , and an Adjunct Professor in the Division of Geriatric Medicine, McGill University and Jewish General Hospital, Montreal, QC.

Harrison’s Principles of Internal Medicine, 15th edition

Harrison’s Principles of Internal Medicine, 15th edition


Harrison's Principles of Internal Medicine, 15th edition

Editors - Eugene Braunwald, Anthony S. Fauci, Dennis L. Kasper, Stephen L. Hauser, Dan L.Longo, J. Larry Jameson

Reviewed by: Shabbir M.H. Alibhai, MD, MSc, FRCPC, Senior Editor, Geriatrics & Aging.

How does an internist go about reviewing a textbook such as Harrison's? A copy of Harrison's has been with me since I began medical school, which already says something, although I'm not sure exactly what. Certainly when one thinks about a short list of great Internal Medicine texts, this book comes to mind. I suspect that almost every reader has encountered Harrison's in one way or another during training or practice. Thus, I approached this review slightly differently. I examined my clinical Internal Medicine practice in the last month to select the last six questions where I required additional information and thought it fair to consult a textbook rather than a specific study. I then evaluated the 15th edition of Harrison's with respect to its ability to answer these questions. The questions were as follows:

  1. In a patient with an elevated growth hormone level, how does one go about making the diagnosis of acromegaly?
  2. What is the best non-invasive test for an older patient with clinically suspected renal artery stenosis?
  3. Which physical exam maneuvres are useful in diagnosing aortic stenosis?
  4. Which groups of patients benefit from perioperative beta-blockers?
  5. How does one treat a patient with relapsed polymyalgia rheumatica (PMR)?
  6. What is the role of testosterone in the treatment of male osteoporosis?

In general, the text is well laid out, and the index is detailed and reasonable to navigate through. The 15th edition maintains the traditional layout of chapters, although in comparison to an earlier edition, there is a larger chapter on genetics and the somewhat sparse chapter on psychiatry has been subsumed in the chapter on neurology. As usual, I was dismayed to find no chapter or even section devoted to geriatrics and related issues (such as the biology of aging organ systems). The text is clear. Tables, charts, figures and flowsheets abound (even more than in previous editions), and there are new symbols to highlight specific headings such as genetic considerations and treatment (although there is no symbol for diagnosis, which is a pity).

So how did it do in terms of my queries? With respect to the question of acromegaly, Harrison's had nice sections on etiology, presentation and diagnosis. It discussed the role of both growth hormone and IGF-1 in screening and the utility of the glucose tolerance test to help rule in or rule out the diagnosis. Unfortunately, there was no mention of the test characteristics (i.e., sensitivity, specificity) but there was a good reference in the bibliography. With respect to the diagnosis of renal artery stenosis, the material provides a useful algorithm (although only in text form) to make the diagnosis, and actually includes some information on the sensitivity and specificity of magnetic resonance angiography as the best non-invasive test (although it does not provide comparative information for other non-invasive tests). When it comes to physical examination of aortic stenosis, classic findings are described, although the emphasis on detailed physical exam is less in this edition, perhaps reflecting the general decline in popularity of physical examination in modern medicine. What is lacking is information about the utility of any specific physical exam maneuvres in ruling in or ruling out aortic stenosis, which would have been more valuable to me than simply listing some common findings in the JVP, the pulse or the apical impulse.

On to therapeutics. After a frustrating time searching for a discussion of perioperative beta-blockade, I found nothing mentioned about this topic. Perhaps I missed it, but it was neither in the index, the table of contents nor selected portions of the text I examined. Moreover, I noted an absence of any section dedicated to preoperative assessment of patients, which was a clear deficiency. With respect to relapsed PMR, I was surprised to find no separate section for PMR. There was little mention of PMR under temporal arteritis either. There was no information on how to treat relapsed temporal arteritis. Finally, with respect to the use of testosterone in male osteoporosis, there was no mention of testosterone as either a standard or an experimental agent to treat osteoporosis, despite considerable recent interest and a small but accumulating body of evidence. For that matter, the discussion on male osteoporosis was virtually non-existent.

At the end of the day, my assessment of the current edition of Harrison's was less than flattering. Perhaps my questions were esoteric or my standards were too high; I will leave that up to the reader to judge. For myself, I would still keep a copy of Harrison's on my shelf, but I am not sure when I would update my older edition and how often I will use this edition. The information in Harrison's is great for summarizing rare diseases and discussing well known aspects of common diseases. But practical information with respect to diagnosis and management was less than I was looking for, despite over 2600 pages of information. And, the lack of emphasis on quality and quantity of evidence was rather disheartening. Maybe it's time to look at online versions of classic texts.

The Time of Our Lives: Why Ageing is Neither Inevitable nor Necessary

The Time of Our Lives: Why Ageing is Neither Inevitable nor Necessary


Orion Books Ltd, London, 1999; 277 pages with index
Reviewed by: A Mark Clarfield, MD, FCFP, FRCPC

As a geriatrician, I did not expect to learn a lot from a book on aging written for the intelligent layman. But I was wrong.

Tom Kirkwood, one of the world's foremost researchers into the study of human gerontology, has written a book that looks deeply and clearly into this fascinating subject--which he rightly calls "one of the last great mysteries of the living world." And, as I tell my medical students, whoever unlocks this secret will no doubt be a candidate for the Nobel Prize in Medicine.

In the preface of this slim volume [Time of Our Lives: Why Ageing is Neither Inevitable nor Necessary] Kirkwood lists the questions that he promises to answer: Why do we age? How does aging happen? Why do some species live longer than others? Do some parts of the body wear out sooner than others? Why do women live longer than men? Why do women have a menopause half way through their life span?

Even if the above-listed puzzles interest neither you nor your patients, this final one should exercise us all, "Can science slow my aging process, or help me age better?" We may not want to grow old, but as a wag once put it, "I prefer old age to the alternative." And, if most of us will try to postpone this particular alternative for as long as possible, how can we hope to age "successfully?"

On the latter subject, the self-help shelves of your local Chapters outlet fairly groan with books touting all kinds of nonsense on the subject. But if you want a clear, concise and scientific answer to the last question for you and your patients, read this book.

Early on, Kirkwood dispels a pernicious notion that unfortunately many gerontologists milk for all it's worth; that is, that the demographic changes we are observing constitute some kind of a catastrophe. That soon the world will comprise a majority of balding cripples demanding an ever increasing portion of the health and social services budgets. As Kirkwood puts it, "There is an unfortunate tendency to see the graying of the world's population as a disaster in the making instead of the twofold triumph that it really is. Firstly, we have managed --not a moment too soon--to begin to bring soaring population growth numbers under control. Secondly, we have succeeded --through vaccination, antibiotics, sanitation, nutrition, education and etc-- in bringing death-rates down."

One of his major points is that despite the rapid increase in the growth of the 80 plus age group, there is increasing evidence (originally from the United States but now supported by Canadian and European data)1 that the period of sickness and disability concentrated at the end of life is actually getting shorter, not longer, as life span increases. These new data add further support to the optimistic prognostications of Crapo and Fries' "Squaring of the Curve" hypothesis.2 In sum, this theory suggests that while maximum life span has not changed much over the past few millenia, average life expectancy (at every age) has increased in the last two hundred years. More to the point, healthy life expectancy has lengthened so that more and more old people are living longer and healthier lives, with the period of end-of-life disability shrinking concomitantly.

One of the most interesting chapters, entitled "What's in a Name?", attempts to define aging and to distinguish it from disease--not an easy task. And Kirkwood admits that despite our supposed familiarity with the process, "…the precise concept of ageing is slippery to grasp, like a bar of soap in a bath." He begins by quoting a British biology professor, J.M. Smith, "Ageing is a progressive, generalized impairment of function resulting in an increasing probability of death."

But we cannot make much sense out of this definition until we understand why we age and how our cells, organs and body gradually lose function. This chapter begins, as do all in the book, with a relevant, pithy quote, in this case from Eubie Blake, the famous jazz musician, on reaching age 100: "If I'd known I was gonna live this long. I'd have taken better care of myself."

Kirkwood attempts to answer the "why" question by elucidating his now famous "disposable soma" theory. The fact that all mammalian species have a fixed maximal life span (e.g., rat: 4 years, elephant: 70 years, Homo sapiens: 120 years) was adduced to support the hypothesis that we are all endowed with "killer" genes, activated by some kind of an internal clock. According to this school of thought, when our time is up, our genes do away with us.

However, Kirkwood does not accept this theory and musters impressive data to refute it. He explains that it is not our genes that actually destroy us--this does not make biological sense. Rather, their function from the evolutionary point of view is actually to keep us going for as long as possible. In the end, it is our bodies (the soma) and not our genes (germ-line) which are disposable. The genes have evolved to invest "…enough in maintenance to enable the organism to get through its natural expectation of life in a wild environment in good shape." From an evolutionary point of view, from which Kirkwood and others insist we must view aging, more than this minimal investment is a waste.

Furthermore, the theory goes on to suggest that there may be design constraints which favour the organism when young at the expense of its long-term durability. A good example would be the central nervous system's once-only development of a fixed network of neuronal connections set down early in life. Despite cell loss over the years and a lack of the usual repair mechanisms, which are present in many of the rest of our organs, the expanded human brain works well for nearly a century but finally begins to "break down" in very old age.

In the end, "natural selection in the wild is not much concerned with late-acting mutations, which may accumulate unchecked within the genome."

He also clarifies the fascinating connection between aging and cancer. After all, the incidence of most tumours rises asymptotically with age and both involve cellular regulatory systems. At first, Kirkwood disposes of the notion that aging is some kind of anti-cancer mechanism:

"It is not. And yet there is a real connection between ageing and cancer, which has, I believe, much to do with the fundamental distinction between the germ-line and the soma. Somatic cells are cheaply made and disposable, but each somatic cell contains within itself the genetic wherewithal to become germ-like again. Cancer is an accidental reversion to a germ-like state."

Therefore, Kirkwood continues, "The same general mechanisms that protect against cancer protect against ageing. This is why long-lived species [such as Homo Sapiens], with their better cellular protection, get cancer later than short-lived species [such as the rat]."

This book explains a complex and fascinating subject with both clarity and panache. Kirkwood, an accomplished scientist, also enjoys the unusual ability for such a professional of being able to write clearly and well. For example, in describing the semelparous form of reproduction (familiar to us through the antics of the salmon) where the parent gives birth and then dies shortly thereafter, he describes in some detail the case of the octopus.

After the babies hatch, the female octopus loses interest in feeding herself and dies shortly thereafter. Kirkwood writes: "In the case of the mother octopus, it is not at all clear why she does not resume normal feeding when the little octopuses hatch. It is not as though she is rushed off her feet&emdash;all eight of them&emdash;ministering to her little one's needs. All she does is die."

Another example of his way with words relates to the menopausal pituitary's upsurge in FSH and LH in an attempt to get the aging ovaries to cycle once again. As Kirkwood puts it, "…the glandular equivalent of yelling over the telephone at someone who is deaf."

My favourite example of his literary style involves Kirkwood's description of the sperm, the main job of which, as we know, is merely to race up the Fallopian tubes seeking out an egg to fertilize. "…and it is therefore no surprise that sperm have evolved to become little more than DNA packages with big outboard motors."

Aging is a fascinating yet paradoxically still understudied subject. Perhaps like its related subject death, we tend to deal with the topic via the psychological mechanism of denial. But how and why we grow old is too interesting and too influential a subject to be ignored for much longer. Kirkwood's book is a good beginning for anyone interested in what will inevitably happen to them and their patients.

And, of course, we must never forget that aging is a process, indeed a long drawn out and relative one. As Oliver Wendell Holmes at age 92 had to say on seeing a pretty girl pass by, "What I wouldn't give to be seventy again!"

Dr. Clarfield, MD, FRCSC, is the Chief of Geriatrics, Soroka Hospital Centre, a Professor and Sidonie Hecht Chair of Gerontology, Faculty of Health Sciences at Ben Gurion University of the Negev in Beersheva, Israel , and an Adjunct Professor in the Division of Geriatric Medicine, McGill University and Jewish General Hospital, Montreal, QC.


  1. Jacobzone S. International challenges: what are the implications of greater longevity and declining disability levels? Health Affairs 2000; 19: 213-25.
  2. Fries JF. Aging, natural death, and the compression of morbidity. N End J Med 1980;303: 130-5.

Victor M, Ropper AH. Adams and Victor’s Principles of Neurology

Victor M, Ropper AH. Adams and Victor’s Principles of Neurology


Seventh Edition. McGraw-Hill 2001.

Reviewed by: David J. Gladstone BSc, MD
Fellow, Division of Neurology, University of Toronto.

The collaboration between Raymond Adams and Maurice Victor dates back to the early 1950s at Massachusetts General Hospital and includes over 100 co-authored papers with seminal descriptions of alcoholic cerebellar degeneration, Wernicke-Korsakoff syndrome, central pontine myelinolysis and normal pressure hydrocephalus. Now in its seventh edition, their Principles of Neurology remains a classic text.

This single-volume work summarizes the core of clinical neurology. The organization follows a logical sequence from "symptom to syndrome to disease." The first half of the book deals with the cardinal manifestations of neurologic disease; the second part is devoted to the major neurologic disorders. The book is strong in its clinical descriptions, classifications and diagnostic approach.

In this era of multi-authored and multi-edited textbooks, the limited authorship of Principles of Neurology is a unique accomplishment that distinguishes this book from many others currently available. It is co-authored with Allan Ropper, Professor of Neurology at Tufts University School of Medicine.

The book has appeal for medical students, trainees and clinicians in general practice, internal medicine, geriatrics, psychiatry and neurosurgery. Many practicing neurologists have a personal copy of this text on their bookshelf but need to consult more exhaustive, multi-volume references for the minutiae. A practical pocket companion book is available separately and may be particularly suitable for students and housestaff.

As so much of neurology involves geriatric medicine, practitioners involved in the care of the elderly will find this book to be a valuable resource. Sections of particular interest to the geriatrician are chapters on The Neurology of Aging, Degenerative Diseases of the Nervous System, Delirium and Other Acute Confusional States, and Disorders of Stance and Gait, among others. General practitioners will find useful sections on seizure disorders, cerebrovascular diseases, tremor and other movement disorders and painful neurologic conditions. Psychiatric illness and neuropsychiatry are given special prominence based on the authors' "belief that these diseases are neurologic in the strict sense." Chapters on pediatric, developmental, metabolic and inherited neurological disorders are also included.

The field of neurology continues to advance at rapid pace and this revised edition is updated with knowledge gained over the past four years, during the culmination of the Decade of the Brain. However, in certain places I found the coverage of neurologic therapeutics to be incomplete or outdated, such as the discussion of Alzheimer disease pharmacotherapy. Readers looking for in-depth discussion of current treatment specifics may need to consult other sources. Neuroimaging and (black-and-white) illustrations are relevant and useful, although the ratio of text to figures is high. Many of the tables are excellent. Additional photographs, imaging scans and colour may enhance future editions.

With the passing of the Canadian-born Maurice Victor on June 21, 2001 at the age of 81 years, this textbook is a legacy of his lifetime of contributions to the practice and teaching of neurology.

Functional Neurobiology of Aging

Functional Neurobiology of Aging


Editors: Patrick R. Hof and Charles V. Mobbs
Academic Press, San Diego 2001, ISBN 0-12-351830-X

Book Reviewed by: Dr. Barry Goldlist

This is a large multi-authored textbook that was developed by the editors to be a source of information for those involved in teaching the neurobiology of aging or doing research in the field. Although the two editors are both Americans, they have recruited many contributors from outside the United States.

The first section is an excellent review of the important concepts of neural aging research. The topics include the epidemiology of age-related neurologic disease, nature vs. nurture in the aging brain and the neurochemistry of receptors. These are clearly reviewed in more detail than is necessary for the casual reader, but are exhaustive and authoritative. The section on the epidemiology of neural aging is superb, and goes well beyond the usual bromides about the aging imperative.

For a practicing geriatrician, I found the chapter on the memory changes that occur with aging and dementia superb. The language is clear and concise, and the chapter gives the reader an excellent understanding of the concept of different memory functions and how they vary in the aging process.

After this, the text becomes very detailed and comprehensive. It is clearly not designed for continuous reading, but rather to be dipped into for specific data and insights. Whatever question I formulated, I could find an answer with relevant references in this text. The first question I asked was "What is the relation between Alzheimer's pathology and disorders with Lewy bodies?" I found an entire subsection on this topic. There are also excellent sections on various treatment modalities in Alzheimer disease.

In summary, this text satisfies its intended objectives to serve as a reference source for those teaching the neurobiology of aging and for researchers in the field. It could also be a useful reference text (probably in the hospital library) for clinicians with an active interest in neurodegenerative disorders.

PC, M.D.: How Political Correctness is Corrupting Medicine

PC, M.D.: How Political Correctness is Corrupting Medicine


By Sally Satel, MD
Perseus Books Ltd. 12/2001
ISBN: 046507183X

Reviewed by: A Mark Clarfield, MD, FCFP, FRCPC

As a physician and as one who is no great admirer of the American system of health care, I was of course intrigued to dig into a book with such a title. Dr. Sally Satel, a practicing psychiatrist and fellow of the American Enterprise Institute, has issued a fierce broadside against the forces that she reckons are "corrupting" American medicine. Dr. Satel gives chapter and verse as to how what she labels "identity politics" [that is, giving preference to women, minorities and even "victims" of psychiatric treatment] has taken precedence over clinical imperatives. In other words, how "political correctness" has deformed the judgement of senior academics, medical and government officials so that not only are patients not helped, but they are actually harmed by the turn that things have taken.

An excellent example would be the movement of those who would "protect" schizophrenics from forced therapy with sometimes catastrophic results for the patient's (and others') health. Although Satel agrees with the purveyors of PC (whom she labels "the Indoctrinologists") that social forces can be a major health determinant, she takes strong issue with the implied notion that we should thus give up our sense of personal responsibility for our health.

The book is closely argued, with multiple examples from the fields of women's health, cancer, psychiatric illness and what she calls the "dumbing down" of nursing education. The book is well referenced and Satel seldom makes a factual point without a citation being listed to support her point.

Indeed, from her litany of complaints, the reader can see that there is indeed a lot remiss in the direction that some elements in the American health system are taking. However, there is unfortunately an element of "the sky is falling" to this book. This tractate is clearly a polemic and a call for action. If we heed not her warnings, "...their prescriptions [those of the Indoctrinologists] will be hazardous to our health."

There is hardly a word in the book about the other ills of American medicine; for example, the waste and inefficiency of it all or the fact that the US health outlay is more than 14% of its GNP (Canada of course spends far less and has better health statistics to boast for her smaller investment). Neither is there a word about the shocking fact that more than 40,000,000 Americans survive without any form of health insurance and that many millions more are underinsured.

Perhaps it should come as no surprise to the reader that Dr. Satel is a fellow of the American Enterprise Institute, not exactly the last bastion of social democracy. Her concern over the beliefs of the "Indoctrinologists" includes her oft-expressed fear that they might succeed in "…social actions that would disrupt our prevailing economic and social systems." Perhaps this is unfair but there is just the whiff of McCarthyism in her style.

The book has the tone not only of a warning. As one reads one example after another of some admittedly rather foolish notions of the PC crowd, I began to think that perhaps the lady doth protest too much. And my initial impression was strengthened by something which appeared in the New England Journal of Medicine (April 12, 2001, pp. 1170-1). In a most unusual move, Dr. Satel wrote to criticize a review of her book which appeared in that journal, protesting strongly what she perceived as a serious slight by the reviewer.

From the Right, Satel rightly criticizes the PC pushers for being more concerned with social and political issues than with the notion of health. However, the book is more of a polemic, albeit with an interesting message, than a sober account of what is so wrong with the American health care system today.

Dr. Clarfield, MD, FRCSC, is the Chief of Geriatrics, Soroka Hospital Centre, a Professor and Sidonie Hecht Chair of Gerontology, Faculty of Health Sciences at Ben Gurion University of the Negev in Beersheva, Israel , and an Adjunct Professor in the Division of Geriatric Medicine, McGill University and Jewish General Hospital, Montreal, Canada.