The main reason I entered the field of geriatric medicine was that in my era of training, almost everybody in internal medicine sub-specialised if they were at all interested in an academic career (fortunately, this is no longer the case). Although I recognised this need for sub-specialisation, I wanted a field where I was responsible for an entire person, not just one disease or one organ. Geriatrics has allowed me to be a sub-specialist but with a generalist point of view, and I have been very happy with my choice.

The one area where my training let me down, however, was in neurology, and I have been scrambling to catch up ever since. It is impossible to provide good care for the elderly without some understanding of neurology and, most importantly, the ability to do an effective screening neurological examination (see "The Neurological Examination in Aging, Dementia and Cerebrovascular Disease", Parts 1-4, in Vol. 5, Nos. 7-10). I suspect that many other physicians are uncomfortable with neurology as well. When I am on the geriatric consultation service, I am always struck by how many significant neurological issues have been missed--or ignored--in the patients that I see. I do not know whether this reflects concern that neurological attention will delay discharge, or a lack of understanding of the benefits of current neurological interventions.

Of course, we do not want our patients to suffer because of missed or ignored neurological conditions. As generalists, we need to understand the common neurological issues in the elderly, learn how to deal with the simpler issues, and refer the more difficult problems to neurologists (whether they be diagnostic or therapeutic). Fortunately, this issue of Geriatrics & Aging will help us in these tasks. There are articles on epilepsy in the elderly, the causes of diplopia, and the etiology and evaluation of dizziness. The management of tinnitus, late-life migraine accompaniments, and numbness and paresthesias in the elderly are also included. These articles will be of particular interest to those caring for the elderly in ambulatory primary care settings.

Drs. Tara Morrison and James Perry have written a review of primary brain tumours in the elderly. The increasing incidence of brain tumours in the elderly (exact reason unknown), combined with the aging of the population, means that these tumours will be seen ever more frequently by all types of physicians. Dr. D'Arcy Little discusses a vexing clinical problem, the drug management of neuropathic pain in the elderly.

We have, as well, several non-neurological articles. Carotid endarterectomy is one of the relatively few surgical procedures that has been well studied in randomised trials, but the literature can sometimes be difficult to interpret. Drs. Claudio Cinà and Catherine Clase summarise the indications and limitations of this common surgical procedure. Two "veteran" social workers with extensive geriatric experience, Helen Levin and Zoë Levitt, review capacity assessment for admission to long-term care. To illustrate how difficult this issue can be, they have chosen some interesting cases. Dr. Maha Haroun has reviewed what is probably the most common dermatological complaint in the elderly, dry skin. The World Health Organization has struck a task force on the issue of elder abuse, and the key issue on which they are focusing is the training of health care providers to recognise elder abuse. Members of the Toronto RGP Elder Abuse Network describe a workshop that has been developed for this purpose.

Enjoy this issue.

Part 4: Reflexes and Sensory Examination

David J. Gladstone, BSc, MD, Fellow, Cognitive Neurology and Stroke Research Unit, Sunnybrook and Women's College Health Sciences Centre, Division of Neurology, University of Toronto, Toronto, ON.
Sandra E. Black, MD, FRCPC, Professor of Medicine (Neurology), University of Toronto; Head, Division of Neurology and Director, Cognitive Neurology Unit, Sunnybrook and Women's College Health Sciences Centre, Toronto, ON.

Abstract
This four-part series of articles provides an overview of the neurological examination of the elderly patient, particularly as it applies to patients with cognitive impairment, dementia or cerebrovascular disease. The focus is on the method and interpretation of the bedside physical examination; the mental state and cognitive examinations are not covered in this review. Part 1 (featured in the September issue) began with an approach to the neurological examination in normal aging and in disease, and reviewed components of the general physical, head and neck, neurovascular and cranial nerve examinations relevant to aging and dementia. Part 2 (featured in the October issue) covered the motor examination with an emphasis on upper motor neuron signs and movement disorders.

Part 2: Motor Examination

David J. Gladstone, BSc, MD, Fellow, Cognitive Neurology and Stroke Research Unit, Sunnybrook and Women's College Health Sciences Centre, Division of Neurology, University of Toronto, Toronto, ON.

Sandra E. Black, MD, FRCPC, Professor of Medicine (Neurology), University of Toronto; Head, Division of Neurology and Director, Cognitive Neurology Unit, Sunnybrook and Women's College Health Sciences Centre, Toronto, ON.

Abstract
This four-part series of articles provides an overview of the neurological examination of the elderly patient, particularly as it applies to patients with cognitive impairment, dementia or cerebrovascular disease. The focus is on the method and interpretation of the bedside physical examination; the mental state and cognitive examinations are not covered in this review. Part 1 (featured in the September issue of Geriatrics & Aging) began with an approach to the neurological examination in normal aging and in disease, and reviewed components of the general physical, head and neck, neurovascular and cranial nerve examinations relevant to aging and dementia. Part 2, featured here, covers the motor examination with an emphasis on upper motor neuron signs and movement disorders.

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.