Practical Dementia Care
The authors, experts in the field of geriatric psychiatry and dementia, offer a clinical treatise on dementia that is good reading for any clinician dealing with the geriatric population. There are several chapters on cortical dementias, including epidemiology, genetics, and pathology. The topics of frontal lobe dementia (frontal lobe, thalamostriatal, and motor neuron), dementia due to Lewy Body disease, and prion dementias are well discussed. Subcortical dementias due to Parkinson's, progressive supranuclear palsy, and HIV infection are intelligently dealt with. Stroke-related, toxic, and brain injury–related cognitive difficulties are addressed as well.
The book is sprinkled throughout with practical clinical pearls, such as the four A's of cortical dementia (amnesia, apraxia, agnosia, aphasia) versus the four D's of subcortical dementia (dysmnesia, dysexecutive, delay, depletion). Discussions on approaching the patient and family give the reader the feel of accompanying the authors on bedside rounds. These sections address complex issues such as guilt and anger. The niceties involved in approaching and discussing a diagnosis of dementia with the family resonated with the experiences of this reviewer. The reader is educated about the use of rhythm, intonation, prosody, and gestures in communicating with demented, possibly aphasic, patients.
Noncognitive psychiatric symptoms, often more disturbing to the caregiver than the memory loss, are approached in a “define/decode/discuss” format. For instance, various causes of episodic screaming are explored, including the important but often-overlooked underlying symptom of pain. There is much practical advice for easing day-to-day caregiving tasks, invaluable in improving a patient's quality of life. The authors recommend, for example, leaving glasses and hearing aids on when a patient is being bathed so as to minimize agitation from reduced sensory input. They address ideal home environments and discuss air travel with a demented patient. Obtaining identical sets of clothing that can then be substituted for soiled sets while a patient is bathing is an ingenious solution to a common problem: some patients are averse to changing clothes.
Approaches to understanding and treating problem behaviors such as insomnia, aggression, rummaging, and hoarding are superb, clearly tapping into the accumulated years of experience of these authors. Pharmacological treatments, including newer medications like olanzapine, are covered. The chapter on legal and ethical issues addresses an area often neglected for physicians.
There was one point of concern for this reader in the stringent criteria stated for determining whether or not a patient with dementia may be left home alone. The authors advocate a companion if a patient has ever been lost outside of the house or if a patient smokes. Although this may be sound for patients with moderate to advanced dementia, in my opinion advocating companions for smokers with early disease is rather conservative. As more patients are diagnosed earlier in the course of illness, and given the more than decade-long natural history of an illness such as Alzheimer's, many productive years may be spent independently without full-time care.
Practical Dementia Care will make a welcome and delightful addition to the libraries of physicians and other health care providers who are involved in the care of persons with memory disorders.
Dr. Devi is director of New York Memory and Healthy Aging Services and an attending physician in the Departments of Psychiatry and Medicine (Division of Neurology), Lenox Hill Hospital, New York, NY.
