Memory Loss: A Practical Guide for Clinicians

Memory Loss: A Practical Guide for Clinicians is, as its authors promise, a practical review of the management of patients with memory loss: examination methods, diagnostic guidelines, differential diagnosis, and treatment, along with useful suggestions for nonmedical management of such concerns as patients’ driving, independent living, need for a power of attorney, and help for caregivers. The authors are clearly experienced in dealing with these topics. The book is generally well written and readable, with the one exception that the many tables disrupt smooth reading of the text. Many chapters begin with tables, and there is considerable repetition between the tables and the text. Those who purchase the print edition of the book are given access to an on-line version. The electronic version makes the content easily available on any computer, allows viewing of color versions of the figures (which are black and white in the print edition), and permits updating of the information. Overall, the volume serves as a “how to” for physicians who treat patients with memory disorders, and should be especially useful for those who staff memory disorders clinics. The Preface establishes the book’s practical approach. There is a minor error: one drug for memory loss, rivastigmine, is approved for dementia with Parkinson disease; hence, the statement that treatments approved by the US Food and Drug Administration (FDA) for memory loss “are all for Alzheimer’s disease” is not strictly correct. Chapter 1 sets the stage, asking the important question, “Why diagnose and treat? ,” and addressing the effectiveness and cost-effectiveness of treatments for memory loss. I found the statement that the cholinesterase inhibitors “turn the clock back on memory loss for 6-12 months” (attributed to Jeffrey Cummings) oversimplified. The response to these drugs is variable: some patients improve, some stay the same, and others continue to deteriorate while taking them. In addition, the drugs help memory, but it is questionable whether they truly turn the clock back on the disease. The evidence is limited that they help other cognitive deficits, for example, praxis, executive function, behavior, and visuospatial functions. The estimated cost of these medications, $1500 to $2000/y, is based on brand name cholinesterase inhibitors; the now generic donepezil, galantamine, and rivastigmine capsules are less expensive. The add-on agent, memantine (Namenda), is still under brand protection as of 2012, and it remains expensive. Chapter 2, an evaluation of the patient with memory loss, is generally very useful, although some clinicians will have difficulty following the authors’ suggestion that they break initial evaluations over 2 or 3 visits and defer the diagnosis until after the first visit. These visits are time consuming, and many practitioners schedule visits only at 6-month intervals, to allow enough time for changes to develop. The discussion of bedside test techniques and imaging studies is generally practical and well organized. I would personally criticize the Mini-Mental State Examination (MMSE) as being too education-bound and too much influenced by verbal skills, but it remains the most widely used test. I do have some criticism of the discussion and figures presenting brain imaging studies. The figure on page 9 is somewhat misleading as to the location of the hippocampus; the top right panel seems to show it extending into the frontal lobe. The magnetic resonance imaging (MRI) figure on page 33 does not mention gradient echo or “T2*” sequences, which are very sensitive to hemorrhage. The text on that page also states that MRI is less sensitive than computed tomography in detecting hemorrhage, but that is not true with the use of these T2* sequences. The presence of microbleeds on T2* is also helpful in the detection of amyloid angiopathy, a fact not mentioned in the text. Further, I believe that it is important to distinguish “small vessel disease” of the white matter from small infarctions, or lacunes. Infarctions, even small ones, are much more closely associated with vascular cognitive impairment and dementia than are the white-matter T2 hyperintensities. A dark signal on T1 or fluid-attenuated inversion recovery (FLAIR) images, especially if the T2* sequence excludes hemorrhage, indicates a small infarction. Finally, a small point: on page 36, the word “dye” is really a slang term; the more proper term is “contrast agent. ” Chapter 3 is a generally excellent summary of the current state of knowledge about Alzheimer disease. As mentioned earlier, the many tables make reading the text somewhat difficult. The diagnostic criteria in the print version of the book are somewhat out of date, given that new criteria were released in 2011, but the on-line version will correct this. Chapter 4, on mild cognitive impairment, clearly summarizes the evidence regarding this controversial disorder. I personally agree with the authors that the introduction of anticholinesterase drugs should not await a definite diagnosis of Alzheimer disease, but should be considered whenever the patient is developing disability. The MMSE does not provide a consistent guide here: a score of 24 may be only mildly abnormal for a person of limited education, but for a person with an advanced degree it represents a significant decline in function. Chapter 5, on dementia with Lewy bodies, is also a good summary of the topic. Rivastigmine is FDAapproved for Lewy body dementia, but the other 2 anticholinesterase medications, donepezil and galantamine, are used “off label,” as the authors state. Memantine is also used off label; The reviewer declares no conflicts of interest. BOOK REVIEW