by Robert H. Paul, PhD, Ronald Cohen, PhD, Brian R. Ott, MD, Stephen Salloway, MD, 372 pp, with illus, $145, ISBN 1-58829-366-1, Totowa, NJ, Humana Press, 2004. If performed well, teaching can be a humbling experience. Trying to explain the current state of a controversial field and responding to even apparently simple questions from inquisitive students can quickly reveal astounding gaps in our knowledge. In the field of dementia, nothing illustrates this as clearly as having to explain vascular dementia (VaD). While many textbooks of neurology indicate VaD as the second leading cause of dementia, journal articles and medical conferences debate the clinical criteria for diagnosis, pathological definition of the disorder, pathophysiological mechanisms, its prevalence, and even the very existence of the disorder. Thus, a clear, well-conceived and well-executed compendium of current thinking on the topic has a lot to offer. Given the state of the field, we obviously cannot expect such a volume to answer all of the existing questions, but to at least summarize the current state of knowledge and frame the important gaps. In this respect, the book does a very good job. The editors of this volume have brought together many distinguished contributors to survey issues on VaD that highlight mechanisms and management. The issues range from clinical phenomenology through diagnosis, and include mechanisms, cognitive aspects, imaging, and management of the disorder. An entire section is devoted to the difficult issue of interactions between Alzheimer disease and VaD. In general, the prose is clear, figures and tables are well placed and illustrate the content well, and the editing is good. As one might expect from a multi-authored volume, chapters vary considerably in many respects including length and depth of analysis, and the approach to the controversial aspects of the disorder. Some chapters contain many pages of exhaustive analysis and review, while others are relatively brief. In general, the length of the chapters is appropriate to the content. With regard to tackling the controversial aspects, 2 general approaches seem to have been taken—the expert review, and the evidence-based review. Evidence concerning many of the controversial aspects of the disorder may obviously be lacking, but nevertheless most chapters are distinguished by a careful review of what is known, or thoughtful critiques of existing dogma. As an example of an exhaustive, thoughtful review, Kurt Jellinger’s chapter on the neuropathology of VaD is a scholarly contribution that is clear in acknowledging controversy where it exists and simultaneously reviewing the available evidence carefully. For example, the chapter reviews the prevalence of the disorder in both clinical and pathological series, pointing out the gaps in knowledge and the difficulties of accurately assessing prevalence in view of the lack of widely accepted clinical and pathological criteria, referral biases, and frequency of mixed dementia. Many useful tables are provided, which review published studies and will give the reader a wealth of data to reference. Many other chapters in the volume are similarly cautiously written and based on evidence. A number of chapters deal with issues of mechanism. Readers will likely find these chapters quite informative as they carefully review issues such as cerebral blood flow and its regulation, genetic and hormonal factors mediating vascular disease, and animal models of hypertension. These chapters carefully review the basic science and do a nice job of linking clinical data to the basic research. The clinical issues related to vascular dementia, including such topics as cognitive characteristics and diagnostic criteria, are particularly difficult areas to review since there is a lack of unanimity about clinical diagnostic criteria and limited clinical-pathological correlation. Furthermore, the inherent problems of circular reasoning, in which clinical characteristics used for diagnosis of VaD are then assessed for prevalence in VaD, can make clinical studies difficult to interpret. In general, the authors of the clinical chapters are aware of these difficulties and carefully describe the limitations of existing knowledge. Some chapters, such as the one by Merino and Hachinski on the topic of diagnosis, are thoughtful reviews of the empirical and conceptual difficulties inherent in making a clinicial diagnosis of VaD given the current state of clinical and basic knowledge. Other chapters review interesting data on issues such as cognitive changes in VaD, with the caveat that much of our knowledge is based on clinically defined syndromes that may be imperfect. A section of the book contains several chapters on brain imaging that review methods (with a particular emphasis on functional and diffusion-weighted magnetic resonance imaging), the important topic of structural magnetic resonance imaging, and the significance of lesions like lacunes and white matter hyperintensities. Chapters on management review pharmacological treatment, quality of life, caregiver burden, and neuroprotection. While one might initially think that these issues may not be very different in VaD compared with other dementias, the authors do a good job of noting the specific issues that are important in VaD. For example, data now available on cholinesterase inhibitors in VaD and issues unique to assessing the quality of life and caregiver burden in VaD patients are nicely reviewed. This volume should be of interest to many different types of individuals. It is probably the research community that would benefit most from such a volume. Many chapters contain nice reviews and tables that would be very useful to someone wanting a summary of available literature on a complex topic. While the controversial and difficult aspects of this disorder are not resolved, most of the authors have done a creditable job of pointing out the limitations in existing knowledge and, as such, the book may help to stimulate new research. Many of the areas of investigation are in flux and data are constantly accumulating, so the revealed clinical wisdom is likely to change. Nevertheless, while the clinical applicability varies from chapter to chapter, there are clearly some chapters that will help guide neuroscience-oriented clinicians such as neurologists, neuropsychologists, and psychiatrists who are involved in the care of elderly patients and patients with dementia. Prose ★★★★ Illustrations ★★★★ Science ★★★ Usefulness ★★★ Back to top Article Information Correspondence: Dr Jagust, Helen Wills Neuroscience Institute, 132 Barker Hall, University of California, Berkeley, CA 94720 (firstname.lastname@example.org).
Archives of Neurology – American Medical Association
Published: Jun 1, 2005