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Neurobiology of Primary Dementia
Book Reviews to die have a psychiatric illness. Some studies have shown that depression is a poor predictor of preferences regarding life-sustaining treatment in the medically ill. We are cautioned that determining whether a person with a serious or terminal illness is competently assessing his/her life and options is a particularly difficult task. We must take pains not to project our own wishes or fantasies into the case lest this cloud our objectivity and cause us to reach a conclusion based on what we, not the patient, wants or needs. Dr. Sullivan, as do the other contributors to this book, believes that we can do more to assure that patients will not opt for suicide. The final sentence of his chapter should be the one that guides our care of the critically or terminally ill: “There is always something that can be done to relieve suffering even if the disease cannot be cured or the life saved.” Julie R. Van der Feen, M.D.C.M., and Michael S. Jellinek, M.D., contribute a thoughtful chapter on end-of-life treatment decisions in children. Herein they discuss the different developmental stages through which children pass, the effect of illness on these stages, and the heartbreak associated with caring for a terminally ill child. Psychiatric consultation for a dying child may require that we play many roles: “diagnostician, healer, bearer of sad news, mediator, counselor, ethicist, or mourner.” This chapter contains four tables (“Questions for physicians and parents dealing with a critically ill child,” “Lifesustaining treatment (LST) decision making,” “End-of-life family assessment issues,” “Questions for follow-up call to the family after a child’s death”) that I found very helpful. They will allay anxiety in the psychiatric consultant who may, quite naturally, struggle for the right thing to say or do during the Psychosomatics 40:3, May-June 1999
consultation or following the death of a child. There is no cure for HIV (human immunodeficiency virus) infection or AIDS (acquired immunodeficiency syndrome). Thus, some with the infection or disease may consider suicide as a viable alternative to the prolonged suffering (be it emotional, physical, or both) they might encounter or are experiencing. Alexandra Beckett, M.D., discusses end-of-life decisions in AIDS cases. We learn that the same demographic (male gender, homosexual, Caucasian race) and psychopathological (depression, alcoholism, organic mental disorders) factors that are associated with an elevated risk for suicide in the non-AIDS population are associated with an elevated risk in this group. Given that many persons with AIDS have more than one of the aforementioned risk factors, so are they at multiple risk for suicide. When assessing competence to forego or stop life-sustaining treatment or requests for PAS, it is important to remember that HIV too easily crosses the blood–brain barrier. Its presence may sufficiently disturb cognitive function, as to make it impossible for the patient to competently understand their condition or to make informed decisions. Other chapters in this book address euthanasia and assisted suicide, legal aspects of end-of-life decision making, termination-of-treatment decisions, and the moral questions concerning PAS. I cannot discuss each one in such short space, but they are equal in all respects to those I have reviewed earlier, that is, well written, concise, informative, and practical. The topic covered in this book is not a pleasant one but is one all psychiatric consultants will deal with during their careers. This text illuminates the major psychosocial issues regarding
end-of-life decisions and does so admirably. It takes difficult topics such as the death of a child or the wish for PAS and gets to the heart of the issue without avoiding the uncomfortable aspects that must be considered if we are to provide informed consultation. The book is well edited. Although there are 14 contributors, they speak as one “voice,” and this is a credit to Drs. Steinberg and Youngner. This book will be useful to C-L psychiatrists and nurses, psychiatry residents, and interested medical students. Remember, there is always something we can do. Dr. Rabinowitz is director of the Psychiatric Consultation Service, Retcher Allen Health Care, Burlington, Vermont; and assistant professor of psychiatry, University of Vermont College of Medicine, Burlington.
Neurobiology of Primary Dementia Edited by Marshal F. Folstein Washington, DC, American Psychiatric Press, 1998 440 pages, ISBN 0–88048-915-4, $61.50 Reviewed by William Falk, M.D.
T
his book delivers more than the title might suggest. Several of the first chapters do concentrate on much of what is known about amyloid betaprotein. The technical discussions about the cellular production, regulation, and the model systems of amyloidogenesis (by Selkoe, Gandy, and Thinakaran and colleagues, respectively) contain authoritative information but can be challenging to the nonresearch clinician. However, those who do take the time to study these chapters are rewarded with an excellent background in this rapidly evolving field. 265
Book Reviews The remaining 15 chapters contain considerable clinical wisdom that would be useful to anyone dealing with demented patients and their families. Threaded throughout the book are chapters that complement and expand upon each other. For example, a clear and concise chapter on familial Alzheimer’s disease (AD) by Bird and colleagues is followed later by Relkin’s lucid critical description of diagnostic markers in AD, their potential utility, and limited current usefulness. Particular attention is paid to the evolving understanding of the Apo E genotypes and their relationship to AD. A subsequent chapter also deserves particular mention because of its wellreasoned, clinically relevant presentation. Susan and Marshal Folstein collaborate on the principles and practice
266
of genetic counseling as it pertains particularly to Huntington’s disease and AD. Rarely do authors provide such specific, concrete, and sensible suggestions on how to deal with this difficult subject. In sections entitled “Deciding what, how and when to give genetic information” and “Methods of transmitting information,” the authors accomplish their goals effectively. A few of the other useful chapter for the clinician include a review of pharmacotherapy of AD by Thal and practical management of dementia by Raskind. In addition, there are chapters that touch upon related areas such as vascular dementia; dementia associated with poststroke depression; and dementia associated with AIDSrelated complex, particularly as the latter informs us about the links between immune reaction and neurode-
generation. I found the chapter on “dementia pugilistica” by Jordan and head trauma as a risk factor for AD by Heyman to bring together considerable information about this understudied area. Although the text is based on a conference held several years ago, the references for each chapter appear to be updated and there is a helpful index to find most of the topics covered. Overall, the book is well-edited, with minimal overlap between chapters. It provided me with a considerable amount of useful information. Dr. Falk is Director of Geriatric Psychopharmacology, Clinical Psychopharmacology Unit, Massachusetts General Hospital; and assistant professor of psychiatry, Harvard Medical School, Boston, MA.
Psychosomatics 40:3, May-June 1999
consultation or following the death of a child. There is no cure for HIV (human immunodeficiency virus) infection or AIDS (acquired immunodeficiency syndrome). Thus, some with the infection or disease may consider suicide as a viable alternative to the prolonged suffering (be it emotional, physical, or both) they might encounter or are experiencing. Alexandra Beckett, M.D., discusses end-of-life decisions in AIDS cases. We learn that the same demographic (male gender, homosexual, Caucasian race) and psychopathological (depression, alcoholism, organic mental disorders) factors that are associated with an elevated risk for suicide in the non-AIDS population are associated with an elevated risk in this group. Given that many persons with AIDS have more than one of the aforementioned risk factors, so are they at multiple risk for suicide. When assessing competence to forego or stop life-sustaining treatment or requests for PAS, it is important to remember that HIV too easily crosses the blood–brain barrier. Its presence may sufficiently disturb cognitive function, as to make it impossible for the patient to competently understand their condition or to make informed decisions. Other chapters in this book address euthanasia and assisted suicide, legal aspects of end-of-life decision making, termination-of-treatment decisions, and the moral questions concerning PAS. I cannot discuss each one in such short space, but they are equal in all respects to those I have reviewed earlier, that is, well written, concise, informative, and practical. The topic covered in this book is not a pleasant one but is one all psychiatric consultants will deal with during their careers. This text illuminates the major psychosocial issues regarding
end-of-life decisions and does so admirably. It takes difficult topics such as the death of a child or the wish for PAS and gets to the heart of the issue without avoiding the uncomfortable aspects that must be considered if we are to provide informed consultation. The book is well edited. Although there are 14 contributors, they speak as one “voice,” and this is a credit to Drs. Steinberg and Youngner. This book will be useful to C-L psychiatrists and nurses, psychiatry residents, and interested medical students. Remember, there is always something we can do. Dr. Rabinowitz is director of the Psychiatric Consultation Service, Retcher Allen Health Care, Burlington, Vermont; and assistant professor of psychiatry, University of Vermont College of Medicine, Burlington.
Neurobiology of Primary Dementia Edited by Marshal F. Folstein Washington, DC, American Psychiatric Press, 1998 440 pages, ISBN 0–88048-915-4, $61.50 Reviewed by William Falk, M.D.
T
his book delivers more than the title might suggest. Several of the first chapters do concentrate on much of what is known about amyloid betaprotein. The technical discussions about the cellular production, regulation, and the model systems of amyloidogenesis (by Selkoe, Gandy, and Thinakaran and colleagues, respectively) contain authoritative information but can be challenging to the nonresearch clinician. However, those who do take the time to study these chapters are rewarded with an excellent background in this rapidly evolving field. 265
Book Reviews The remaining 15 chapters contain considerable clinical wisdom that would be useful to anyone dealing with demented patients and their families. Threaded throughout the book are chapters that complement and expand upon each other. For example, a clear and concise chapter on familial Alzheimer’s disease (AD) by Bird and colleagues is followed later by Relkin’s lucid critical description of diagnostic markers in AD, their potential utility, and limited current usefulness. Particular attention is paid to the evolving understanding of the Apo E genotypes and their relationship to AD. A subsequent chapter also deserves particular mention because of its wellreasoned, clinically relevant presentation. Susan and Marshal Folstein collaborate on the principles and practice
266
of genetic counseling as it pertains particularly to Huntington’s disease and AD. Rarely do authors provide such specific, concrete, and sensible suggestions on how to deal with this difficult subject. In sections entitled “Deciding what, how and when to give genetic information” and “Methods of transmitting information,” the authors accomplish their goals effectively. A few of the other useful chapter for the clinician include a review of pharmacotherapy of AD by Thal and practical management of dementia by Raskind. In addition, there are chapters that touch upon related areas such as vascular dementia; dementia associated with poststroke depression; and dementia associated with AIDSrelated complex, particularly as the latter informs us about the links between immune reaction and neurode-
generation. I found the chapter on “dementia pugilistica” by Jordan and head trauma as a risk factor for AD by Heyman to bring together considerable information about this understudied area. Although the text is based on a conference held several years ago, the references for each chapter appear to be updated and there is a helpful index to find most of the topics covered. Overall, the book is well-edited, with minimal overlap between chapters. It provided me with a considerable amount of useful information. Dr. Falk is Director of Geriatric Psychopharmacology, Clinical Psychopharmacology Unit, Massachusetts General Hospital; and assistant professor of psychiatry, Harvard Medical School, Boston, MA.
Psychosomatics 40:3, May-June 1999