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Book Forum: Dementias   |    
Practical Dementia Care
MICHAEL R. BIEBER, Ph.D.
Am J Psychiatry 2001;158:1948-1948. doi:10.1176/appi.ajp.158.11.1948
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By Peter V. Rabins, M.D., M.P.H., Constantine G. Lyketsos, M.D., M.H.S., and Cynthia D. Steele, R.N., M.P.H. New York, Oxford University Press, 1999, 278 pp., $34.95.

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The title of this book is most appropriate because the authors reveal in their work the importance of psychiatric care for demented patients and their commitment to this care. Demented patients are not just medical cases with particular diseases, but patients with a disease who have specific and practical needs for care. As patients with dementia become ill, their reliance on others increases significantly. The quality of the response to these patients often determines whether their capacities and emotional balance can be enhanced. These patients can be helped substantially.

The authors write well, mostly without jargon and in direct, clear statements, so reading this book is easy and inviting. They are interested in patients with dementia and have something to say about how they can be helped.

The first third of the book covers definitions, evaluations, and formulations of dementias. Dementia is considered a syndrome associated with a decline in cognitive capacity; multiple areas of cognition are affected, but there is a normal level of consciousness. Two types of dementia-based patterns of cognitive impairment are recognized, cortical and subcortical. Cortical dementias are distinguished by the loss of cognitive capacities and the capacity "to do." Patients with subcortical dementia lose the ability to coordinate cognition but often can "do it." For example, a patient with cortical dementia can’t remember and can’t do things, but a patients with subcortical dementia may think slowly and need clues but can remember or "do" with aids.

The dementias associated with cortical syndromes are described in one chapter: Alzheimer’s, frontotemporal degeneration, disseminated Lewy body disease, and the prion dementias, along with their distinct clinical picture, epidemiology, and pathology/etiology. In the following chapter, the diseases associated with a subcortical or mixed pattern of dementia are described: Parkinson’s, progressive supranuclear palsy, Huntington’s, normal pressure hydrocephalus, multiple sclerosis, HIV and AIDS, cerebrovascular disease, depression-induced cognitive impairment, traumatic brain injury, and various toxicities. The authors stress the importance of making a specific diagnosis of the cause of dementia because this conveys important knowledge about prognosis and, therefore, more effective treatment.

There are good chapters on supportive care for demented patients and on supporting the family caregiver. Following this is an excellent discussion of common behavioral and psychiatric problems seen in the dementias (catastrophic reactions, resistance to care, apathy, aggression, wandering and pacing, hoarding, yelling, mood disorders, and hallucinations and delusions) and their understanding and suggested treatments.

There is a good discussion on pharmacological treatment of the dementias that covers cholinesterase inhibitors (tacrine and donepezil), antipsychotics (atypical agents are usually preferable because of fewer and milder side effects), and antidepressants and mood stabilizers. Selective serotonin reuptake inhibitors are usually preferable to tricyclics.

The book ends with very useful and thoughtful suggestions for handling the terminal phase of dementia and about ethical and legal problems. For example, should a severely demented patient be told of their spouse’s death? Probably not, because it may lead quickly to the patient’s own death and it serves no purpose.

This is a very good book for those of us working with demented patients. I strongly recommend it.

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