Book Reviews. Department of Psychiatry and Behavioral Sciences Northwestern University, Chicago, Illinois

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1 Iwernational Psychogeriatrics, Vol. 3, No. I, Springer Publishing Company Book Reviews Reviewed by George H. Pollock, M.D., Ph.D. Department of Psychiatry and Behavioral Sciences Northwestern University, Chicago, Illinois Emotional Problems in Later Life: Intervention Strategies for Professional Caregivers. Dan Blazer. New York: Springer Publishing Company, xi pp. $29.95, hard cover. Dan Blazer, M.D. is an internationally renowned researcher, teacher, and administrator. In addition to his medical and psychiatric expertise, he also is the holder of a Ph.D. in epidemiology. This combined expertise is in evidence in some of his outstanding research in late-life depressions and their sequelae. At present Dr. Blazer is professor of psychiatry, director of the Affective Disorders Program, and senior fellow at the Center for the Study of Aging at Duke University. He is the author of nearly 100 articles in professional journals, many book chapters, and author, co-author, or editor of eight books, including Geriatric Psychiatry, which he co-edited with E. W. Busse in In this exciting era when geropsychiatry has become an official subspecialty, it is very useful and encouraging to read Dr. Blazer s reports and essays on aging. The present volume is no exception, although its focus is not on depth research in the field. In some ways it is an introduction to geropsychiatry. As such, it is useful for the generalist, the student, the resident, and the nonpsychiatric practitioner who wishes to gain an accurate overview of this increasingly important area of service, research, and administration. Blazer clearly indicates that his focus is on specific entities that signal the cry for help, either from the family or the individual himself. As he indicates in his Preface, A problem-oriented approach to emotional problems is the foundation of sound clinical reasoning (p. v). From this reasoning, a course of future intervention, or at times no-intervention, is charted. Understanding the meaning of symptoms and signs is the hallmark of medicine, especially of psychiatry, for individuals of all ages. For the elderly we may observe specific behaviors, thought disorders, and affective pathologies that call for special understanding: a complete problem list or even a complete biopsychosocial (and spiritual) evaluation of the elder can never be equated to the existential understanding of the older person obtained by dialogue and observation through time. Lab values, symptom lists, behavioral inventories, and functional assessments are no more than tools that enable professionals to rate observations and compare behavior across persons. The comparison 79

2 80 Book Reviews across individuals comprises the science of clinical practice... within the context of his or her unique life experience (p. vi). This philosophy again can be applied to all of medicine and psychiatry. Blazer utilized Engel s biopsychosocial approach to his essays on the emotional problems of later life. Perhaps we now can and should speak of the biopsychosocial developmental approach to all psychiatric illness. This approach did not result in reductionistic explanations but gives us a framework to facilitate our understanding of complex situations in a way that helps understand the individual with the problems, where the problems may have originated, why they have been perpetuated or exacerbated, and what types of interventions are possible to alleviate the effects of these antecedents. This book is divided into 13 chapters. We first are introduced to the demographics of the elderly, and how the biopsychosocial developmental model can be used with this ever growing population. The second chapter focuses on communication with the older adult suffering from emotional problems. In this chapter Blazer logically differentiates perceptual (both physical and sensory) and psychological impairments. The psychosocial bamers to communication focus on the patient and on the negative attitudes of the professionals which can easily be noted by the patient and result in communication resistance. The brief discussion of techniques for effectively communicating with the older adult includes means of improving hearing loss and visual loss. The social-cultural bamers perhaps also should be included in this well-written brief exposition. Speech therapy, hearing aids, cataract surgery can all be means of improving the impaired elder s participation in the environment. Attention to nonverbal communication, allowing enough time for meaningful interaction, sensitivity to the privacy needs, clear and understandable discussions by the professional, structured and unstructured inquiry and reference to nursingnotes, discussions with other caretakers can provide additional information to the diagnostician. With Chapter 3, Blazer begins his discussion of specific impairments in the elderly, e.g., memory loss, dementia, delirium, late-life depression, symptoms of suspiciousness and agitation, anxiety, hypochondriasis and somato form disorders, sleepdisorders, alcohol and drug abuse, emotional reactions to physical illness, and bereavement. The reviews of the specific disorders are brief yet comprehensive and include differential diagnostic considerations. The interspersing of summarized clinical vignettes clarifies those discussions. Each chapter includes a section on the diagnostic work-up and treatment management. Chapter 12 deals with the crucial area of Working with the Family of the Older Adult Suffering Emotional Prdblems -a very useful discussion of an area of concern we increasingly encounter in our daily work. The last chapter of this valuable book deals with Successful Aging. Blazer, utilizing a clinical example, discusses the concept of successful aging along the following lines: vitality, resilience, adaptive or coping ability, autonomy and control, integrity and integration ability, wisdom and social integration. Personal health habits, exercise, proper care of teeth and gums, weight control, monitoring

3 Book Reviews 81 of physical status, life-long learning and activity are topics discussed in this final chapter. Each chapter has an up-to-date listing of useful and timely references and an additional list for further reading. The index is useful. Dr. Blazer has done an excellent job in addressing the theme of his book - and all in a total of 260pages! This volume should be read by all professionals who work with the elderly and who themselves are aging. The brevity, clarity, and comprehensiveness make it a must as an introduction to geropsychiatry, geropsychology and gerontology. For those who have more experience, reading this book is a way of updating one s existing information and augmenting one s clinical experiences. Memory, Aging, and Dementia: Theory, Assessment, and Treatment. Grover C. Gilmore, Ph.D., Peter J. Whitehouse, M.D., Ph.D., and May L, Wykle, Ph.D., R.N., EA. A.N., editors. New York: Springer Publishing Company, pp. $35.95, hard cover. The title of this edited volume addresses three of the most important areas confronting geriatricians, geropsychiatrists and geropsychologists, and gerontologists-aging, memory, and dementia. I change the order from that of the title because I feel one goes from the more general to the specific, and this is true here. The editors, all from Case Western Reserve University, indicate that several hundred people from the fields of medicine, nursing, psychology, and social work attended a conference in Cleveland in October 1987 to discuss the topics this volume addresses. The presentations and discussions were edited and published in the book here reviewed. The objectives of this monograph can be summarized into: (1) a presentation of contemporary models of memory, especially as they relate to an understanding of the memory performance of healthy and impaired elderly adults ; (2) what interventions and approaches can be utilized to improve the memory performance of both healthy and demented elderly adults ; (3) what are the impacts that severe cognitive impairment can have on the family and the caregivers of patients with dementia ; and (4) what are the medical issues related to Alzheimer s disease by examining the recent evidence on the biological determinants of Alzheimer s disease and... the difficulty of clinically diagnosing the disease (p. ix). The concluding discussion focuses on how effective our current health and disease delivery systems can be that deal with the needs of our ever increasing aging populations. These needs extend beyond memory and dementia - e.g., medical, social, economic, psychological needs which require our attention. But these are beyond the purview of the present volume. Memory impairment, though a major symptom and sign of older individuals, is so fundamental an issue that it extends beyond the life course period of the elderly. It is most prominent in this age group but one can detect declines in retention and

4 82 Book Re~iews recall in much younger adults. Some may feel this forgetting is mainly due to psychological blockage, others believe it is due to beginning organic decline, and still others see this phenomenon as a combination of biological, psychological, and social factors. The degree and type of memory loss or decline, the resurrection of that which seemingly is forgotten, the profundity of the memory loss are significant factors that must be determined diagnostically and then interventive measures introduced, if possible, to reverse these at times very concerning deficits. As the editors note, there are multiple facets to memory and its deficits. Although psychologists have studied memory for many years, it is only since there has been an emphasis on Alzheimer s disease that more attention is being directed to this crucial aspect of our lives. After all is said-we are our memories. Who we are, where we came from, who are the significant shaping figures of our past, what are our goals in life, whom we look to for support and help-all are related to our organized memory structures. Without these, we have no self and are reduced to biological machines. Dementia includes more than Alzheimer s disease and now we can begin to determine such diagnostic differentiations. These will be increasingly important in our approaches to assessment, diagnosis, intervention, treatment and care, and relationships with families of the victims of these disorders. Unfortunately there is insufficient emphasis in this volume on the emotional problems of the victims of the diseases and their families and caretakers. The volume consists of three parts and each part has a number of specific chapters that relate to the theme of the given section. The first part on memory and aging is the longest section of this volume. It contains eight separate chapters on memory. It is an excellent, relatively brief overview of the state of our knowledge, which expands daily, of the theory, assessment, and diagnosis of memory impairments. The second part has two chapters devoted to biochemical and genetic aspects of Alzheimer s disease and related disorders-as well as diagnosis and treatment. The final section is mainly devoted to various aspects of Alzheimer s disease, e.g., perspectives from nursing, psychology, social work, and health care delivery, and how one can, if possible, facilitate new learning in Alzheimer s disease. This compendium can be useful to workers in the field, specialists, researchers, teachers, and students. It also can be the basis of future volumes which will update our knowledge, skills, attitudes, and policies in dealing with the problems of the demented elderly-an issue that will not go away and one that we all must actively consider from various dimensions, i,e., cost, politics, intergenerational issues, and the prioritization and rationing of care. This volume and its contributors stimulate much thought about what faces us now and in the future.

5 Book Reviews 83 Psychiatric Consequences of Brain Disease in the Elderly: A Focus on Management. David K. Conn, Adrian Grek, and Joel Sadavoy, editors. New York and London: Plenum Press, pp. $50.00, hard cover. As our knowledge about particular diseases, segments of the life course, basic molecular mechanisms, biotechnology, and other specific aspects of health and disease rapidly increases, we find shifts in how information is transmitted from researcher to clinician and from practitioner to practitioner. Also, given a marked increase in mandatory continuing education, the use of practice parameters, relicensure, recertification in specialty and subspecialty areas, it becomes difficult for one presenter to cover large areas in single review and update courses. What has evolved are symposia, conferences, and postgraduate programs presented by clinical and basic science researchers who are specialists in particular areas. These specialized programs, usually sponsored by universities, specialty groups, and even commercial entrepreneurs, offer continuing education credit for a fee. In some instances the presented papers are collected, edited, and if there are areas that are not discussed, solicited papers are invited to fill in the lacunae. These edited volumes vary in length, quality, and depth. Some, like the present anthology under review, fill a need in exemplary fashion. Others are either too superficial, too broad and general, too technical and detailed, or too expensive. Having stated my current assessment of edited volumes derived from conferences, let me turn to the specific book under review. Psychiatric Consequences of Brain Disease inthe Elderly: A Focus on Management is edited by three Canadian colleagues but includes contributions by colleagues from the United States. The editors have focused the collection on clinically relevant issues, utilizing case illustrations whenever possible. The volume has a bio-psycho-social emphasis and how this relates to intervention strategies. The scope is such that it can be useful to all professionals who work with the elderly in various settings. The first chapter, prepared by David Conn, is an excellent overview of the neuropsychiatric syndromes of the elderly. A brief review of brain structure, diagnostic considerations of the dementias, deliriums, amnestic syndromes and hallucinations, delusions, organic personality disturbances, and drug reactions is presented. There is a brief but meaningful discussion of psychiatric consequences and treatment of stroke, Parkinson s disease, the dementias, Huntington s disease, motor neurone disease, as well as less frequent disturbances. There is an abundance of clinical illustrations, and the reference list is comprehensive, current, and can be very useful to those who wish further details on what is described in the text. The second chapter briefly describes the investigation of neuropsychiatric disorders. The third chapter discusses the pharmacologic management of neuropsychiatric syndromes. The emphasis on organic affective disturbances, thought disorders, as well as on the syndromes described in earlier sections of the

6 84 Book Reviews collection of essays, is quite useful as is the comprehensive bibliography. The brief but very stimulating chapter on Psychodynamic Perspectives in the Clinical Approach to Brain Disease in the Elderly by Gene Cohen is excellent. It provides a perspective that could otherwise be ignored if one focused only on the organic modes of therapy for brain- impaired patients. Cohen s chapterleads nicely into the next excellent discussion of various psychotherapies for the cognitively impaired elderly. Joel Sadavoy and Anne Robinson, the authors, include different psychotherapeutic approaches, e.g., behavioral, group, milieu, family, and individual psychotherapy. The case reports and the techniques for intervention are very good and illustrate theoretic discussions presented earlier. The next presentation by Graham Berman on Helping the Family flows naturally from the preceding chapters. It discusses family systems, networks, family treatment and self-help groups. Chapter 7 on management of disruptive behaviors in the cognitively impaired elderly integrates the neuropsychological and behavioral approaches, especially in rehabilitative programs. The model outlined for use by clinicians who work with the cognitive disorders is clear and very useful. The clinical data to which this model is applied are helpful in understanding the application of Guy-Bernard Proulx s approach at the Baycrest Centre for Geriatric Care in Toronto. The research reported can be usefully applied by investigators of allied problems that need a systematic methodology. Sheldon Tobin s essay on Issues of Care in Long-Term Settings reflects his prior pioneering work on the institutionalization of the old as well as an updating of some of his ideas and research findings. His discussion of Predicting Vulnerability to the Stress of Institutionalization (pp ) is especially useful and important. The clinical illustrations make his report particularly useful to caretakers who are called upon to intervene in the care course of the institutionalized individual and his or her fcimily. The collection ends with a brief finale that focuses upon the differentiation of needs from wishes and the integrated approach to psychiatric and geriatric patients. This relatively short book has much knowledge, wisdom, experience and literature mastery in it. The student, researcher, teacher, clinician, and administrator can learn much by reading the various reports. The Merck Manual of Geriatrics. William B. Abrams, M.D. and Robert Berkow, M.D., editors. Andrew J. Fletcher, M.B., B. Chir., Assistant Editor. Rahway, New Jersey: Merck & Co., pp. The new Merck Manual of Geriatrics is the first additional Merck Professional Handbook since the Merck Veterinary Manual first appeared in The Merck Index was first published in 1889 and the widely used and well-known first edition of the Merck Manual of Diagnosis and Therapy was issued in These handbooks have been revised and updated since then; however, the 1990 Merck Manual of Geriatrics is a new publication and attests to the increasing importance

7 Book Reviews 85 of the care of elderly patients by clinicians. The editors, W. B. Abrams, M.D. and R. Berkow, M.D., indicate that a geriatric medical book was under consideration for several years and now in 1990 it has come into being, as there are special issues involved in the care of older adults that a general textbook of medicine cannot include. The editors indicate that demographic imperative and special clinical aspects of treating elderly patients make this volume uniquely valuable and needed. As is well known, There are more Americans over 65 than under 25 for the first time in history and the average age is steadily increasing (p. v). It is anticipated that by 2030,20% to 50% of all health resources of this country will be utilized by this older segment of our population. Furthermore, basic physiological and psychosocial research of normal aging (gerontology) is increasing in importance and in amount. Geriatrics as a specialty is recognized and geropsychiatry is now officially a subspecialty of psychiatry leading to special competence designation. The geropsychiatrist now has available in this concise, well-written, comprehensive manual, the medical data as well as excellently written condensed descriptions of geropsychiatric syndromes. There are differences in how diseases manifest themselves in older adults as contrasted to the presentation in younger patients. Furthermore, what may be signs and symptoms of illness in older adults may have different meanings and significance when seen in younger patients. In similar fashion, we know that older adults respond differently to some drugs than do younger adults, and the questions of drug interactions and psychiatric and psychologic effects of drugs used for physical illnesses may be overlooked by therapists. Complexity and multiple variables must be considered in pharmaceutical utilization for whatever reason the initial drugs are used. The question of side effects must also be kept in mind. Thus a practical handbook on geriatrics is indicated and can be very useful. The editors begin with a section discussing problem-oriented diagnostic approaches to common symptom and sign presentations of older patients. The second section deals with more specific approaches to management issues, and the third section focuses on specific disorders and diseases of individual organ systems. There then is a section dealing with epidemiologic, social, ethical, financial and legal issues (p. vi), and the concluding section has various reference tables and other data that are unique for the older patient. The various sections, written by outstanding and recognized leaders in their fields of geriatric subspecialties, include discussions by such well-known geropsychiatrists as Dan Blazer, Robert Butler, Gene Cohen, Susan and Marshal Folstein, and Robert Nathan. This very valuable manual should be available to all clinicians who work with olderadults. Its compactnessmakes itveryuseful and canlead the interested reader to other presentations where specific topics are discussed in depth. Students especially will find it a useful first-level guide.