Vascular Dementia: Cerebrovascular Mechanisms and Clinical Management
http://www.100md.com
《新英格兰医药杂志》
Hardly a week passes without a new report describing an association between vascular risk factors and dementia. With our rapidly growing elderly population, dementia is becoming an increasing public health burden. This book is an update on the link between cerebrovascular disease and dementia. Although several other books have been published on the subject, there is still a need for a definitive work that reduces ambiguity about what vascular dementia is and what we might do about it, and this one fits the bill.
In addition to the introductory section, this six-part overview of vascular dementia has sections on basic disease mechanisms, the effect of the disorder on clinical findings, imaging, treatment, and the elusive relationship between Alzheimer's disease and vascular dementia. Contributed by distinguished authorities in their fields, the chapters flow smoothly enough to be read cover to cover; however, most readers will probably choose to use the book as a reference. There are no major conflicts in information or duplicated sources among the authors of the various chapters.
The book has several strengths. It is extensively referenced. The diagrams, images, and tables are generally thoughtful. A chapter on the challenges of diagnosis provides a helpful table summarizing the various criteria. This table and the accompanying information help reduce confusion regarding the strengths and uses of each of the principal sets of diagnostic criteria. One of my favorite chapters is on cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL), linking everything from the genetic abnormality and pathogenesis to clinical symptoms. Another chapter does an excellent job of outlining neuropsychological features that help distinguish between Alzheimer's disease and subcortical vascular dementia.
One criticism of the book is that little attention is focused on the fascinating issue of whether cerebrovascular disease or cerebrovascular risk factors worsen the Alzheimer's disease process. For example, little mention is made of how diabetes or insulin dysregulation affects beta-amyloid aggregation and tau phosphorylation. Chapter 19 comes close by briefly stating that thrombin induces secretion of the amyloid precursor protein and that thrombi in small blood vessels may reduce beta-amyloid clearance. The section on imaging in vascular dementia has few examples of magnetic resonance imaging (MRI); it would have been useful to have included more. For instance, imaging studies of elderly subjects often show some degree of "nonspecific white matter change." MRI scans that show various levels of small-vessel vascular burden, correlated with cognition, would give the clinician a sense of when subcortical ischemic change is likely to be clinically significant.
Reading between the lines, one perceives the message that there are few cases of pure vascular dementia. This is an important point for the physician to consider when conceptualizing an approach to the treatment of patients with dementia. Thus, it encourages the reader to view dementia as often multifactorial, rather than a disorder that can be routinely compartmentalized into a single cause. The final part of the book, titled "Clinical Management of Vascular Dementia," summarizes data supporting the use of each of the foremost cholinesterase inhibitors in the treatment of vascular dementia and the need for additional clinical trials, including those involving neuroprotective agents. An additional chapter discussing the effect of aggressive management of vascular risk factors on the clinical course of vascular dementia would have made the section even stronger.
Overall, Vascular Dementia is a valuable textbook. After reviewing it, I felt as if I had been brought up to date on a variety of topics related to the disorder, including age-related alterations in cerebral hemodynamics, CADASIL, functional brain imaging, and the potential importance of cerebral endothelial cells. I would recommend the book to geriatricians, internists, and neurologists who care for elderly patients as well as to clinical researchers in geriatric neurology.
Carol F. Lippa, M.D.
Drexel University College of Medicine
Philadelphia, PA 19129
clippa@drexelmed.edu
In addition to the introductory section, this six-part overview of vascular dementia has sections on basic disease mechanisms, the effect of the disorder on clinical findings, imaging, treatment, and the elusive relationship between Alzheimer's disease and vascular dementia. Contributed by distinguished authorities in their fields, the chapters flow smoothly enough to be read cover to cover; however, most readers will probably choose to use the book as a reference. There are no major conflicts in information or duplicated sources among the authors of the various chapters.
The book has several strengths. It is extensively referenced. The diagrams, images, and tables are generally thoughtful. A chapter on the challenges of diagnosis provides a helpful table summarizing the various criteria. This table and the accompanying information help reduce confusion regarding the strengths and uses of each of the principal sets of diagnostic criteria. One of my favorite chapters is on cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL), linking everything from the genetic abnormality and pathogenesis to clinical symptoms. Another chapter does an excellent job of outlining neuropsychological features that help distinguish between Alzheimer's disease and subcortical vascular dementia.
One criticism of the book is that little attention is focused on the fascinating issue of whether cerebrovascular disease or cerebrovascular risk factors worsen the Alzheimer's disease process. For example, little mention is made of how diabetes or insulin dysregulation affects beta-amyloid aggregation and tau phosphorylation. Chapter 19 comes close by briefly stating that thrombin induces secretion of the amyloid precursor protein and that thrombi in small blood vessels may reduce beta-amyloid clearance. The section on imaging in vascular dementia has few examples of magnetic resonance imaging (MRI); it would have been useful to have included more. For instance, imaging studies of elderly subjects often show some degree of "nonspecific white matter change." MRI scans that show various levels of small-vessel vascular burden, correlated with cognition, would give the clinician a sense of when subcortical ischemic change is likely to be clinically significant.
Reading between the lines, one perceives the message that there are few cases of pure vascular dementia. This is an important point for the physician to consider when conceptualizing an approach to the treatment of patients with dementia. Thus, it encourages the reader to view dementia as often multifactorial, rather than a disorder that can be routinely compartmentalized into a single cause. The final part of the book, titled "Clinical Management of Vascular Dementia," summarizes data supporting the use of each of the foremost cholinesterase inhibitors in the treatment of vascular dementia and the need for additional clinical trials, including those involving neuroprotective agents. An additional chapter discussing the effect of aggressive management of vascular risk factors on the clinical course of vascular dementia would have made the section even stronger.
Overall, Vascular Dementia is a valuable textbook. After reviewing it, I felt as if I had been brought up to date on a variety of topics related to the disorder, including age-related alterations in cerebral hemodynamics, CADASIL, functional brain imaging, and the potential importance of cerebral endothelial cells. I would recommend the book to geriatricians, internists, and neurologists who care for elderly patients as well as to clinical researchers in geriatric neurology.
Carol F. Lippa, M.D.
Drexel University College of Medicine
Philadelphia, PA 19129
clippa@drexelmed.edu