Memory Loss—A Practical Guide for Clinicians

28 December 2011. The U.S. is confronting a crisis of Alzheimer’s disease as the current number of five million people with AD is expected to swell threefold by 2050. Who is going to diagnose and treat them? “There are just not enough specialized neurologists, psychiatrists, and geriatricians to take care of the millions of people who have, or will have, Alzheimer’s,” said Andrew Budson, at the Veterans Affairs Boston Healthcare System, Massachusetts.

Budson told Alzforum he believes that the burden of diagnosing and treating Alzheimer’s long-term will largely fall on general neurologists and even primary care physicians. In Memory Loss—A Practical Guide for Clinicians (Elsevier Saunders), Budson and coauthor Paul Solomon of Williams College, Williamstown, Massachusetts, provide a comprehensive overview of the evaluation, diagnosis, and treatment of people with memory disorders.

Murali Doraiswamy, Duke University Medical Center, Durham, North Carolina, calls it a gem of a book. “It is up to date, has crystal clear organization, and is packed with tables and charts addressing the most important things a clinician is looking for,” he told ARF via e-mail. Doraiswamy recently co-wrote his own guide to coping with early-stage Alzheimer’s (see ARF book review).

Budson and Solomon's book falls into six sections over 25 chapters. Each chapter begins with a “quick start” bulleted summary. The first section deals with patient evaluation. Budson and Solomon take the reader through the steps of talking with the patient and the family, reviewing patient history for disorders that may predispose or explain memory loss, and through physical and cognitive examinations. The authors review cognitive tests and questionnaires, detailing the routinely used Mini-Mental State Examination and other more extensive tests such as the Blessed Dementia Scale, and simpler, faster cognitive tests such as the AD8 (see Alzforum Webinar), and they explain neuropsychiatric assessments, including the Neuropsychiatric Inventory. The authors also provide an overview of the main structural and functional imaging techniques being used to aid diagnosis (see ARF related news story).

In section two, the authors address the complicated issue of differential diagnosis. While Alzheimer’s is the most common form of dementia, it is easy to confuse it with other disorders that cause memory loss, including dementia with Lewy bodies, frontotemporal degeneration, and vascular dementia. Budson told Alzforum that most clinicians are reluctant to attempt a differential diagnosis without being trained, and it was partly with this in mind that they wrote the book. In chapters devoted to the most common memory disorders, Budson and Solomon outline the characteristics of each, including how patients present during the evaluation procedures outlined in section one. They devote most space to Alzheimer’s, but readers will learn to recognize specific traits indicative of other memory disorders. For example, changes in personality and social conduct are often a sign of frontotemporal dementia, or a perceived “alien limb”—an arm or leg that seems to have a mind of its own—is a sign of corticobasal degeneration. The book is richly illustrated with histology and brain imaging data to help the reader understand the underlying pathology driving each disease.

The third section of the book covers treatments, both those currently approved for AD (acetylcholinesterase inhibitors and the NMDA glutamate receptor antagonist, memantine) and those being pursued in clinical trials. Section four is devoted to behavioral and neuropsychological symptoms of dementia. These are the most difficult to treat, and often the reason for placing people with dementia in full-time care. Section five addresses issues such as changes to lifestyle that await patients and their families. Doraiswamy told ARF that the 10 case studies outlined in section six are excellent teaching and self-assessment tools.

From the point of view of the busy clinician working in the trenches but looking for a practical and cutting-edge guide, Doraiswamy said he cannot think of a better book, noting, “This is the clinical book of the year in our field.”

The authors plan to keep this guide up to date electronically. Each book comes with an activation code that allows the reader to access its online version. For example, the recent National Institute on Aging/Alzheimer's Association guidelines for the diagnosis of AD (see ARF related news story) came out after the book had gone to print and are covered in a dedicated section in the online version.—Tom Fagan.