Introduction to the Dementias Dementia and Alzheimer Disease Alzheimer Disease Dementia and Society Dementia and DSM Beyond DSM Beyond Dementia References

Alzheimer Disease and Other Dementias

In a world of ever-growing cognitive complexity, the threat of Alzheimer disease and other cognitive impairments that seem an inevitable part of aging is, on one hand, frightening, and on the other, a call to arms. We are faced with an increasing number of persons with dementia around the world, both in absolute numbers and in percentage of the population. This rise is in part due to greater survival of the normally aging world population and persons with chronic illnesses, head injuries, and other factors affecting brain function. As you will read on our site, our awareness of dementia has a long history with wide and varied attribution from immorality to evil. From these primitive beginnings, the community of clinicians and scientists has moved to an age of reasoning and inquiry that has created a nosology and diagnostic criteria, developed a knowledge of accompanying pathology, designed trials to test treatments, evaluated psychosocial interventions, provided support to caregivers, and championed the work to preserve the quality of life of those who are afflicted. There has been a virtual explosion of knowledge concerning the dementias in the past 30 years, and scarcely a day goes by that the media fail to mention the possibility of a new treatment for Alzheimer disease.

Psychiatrists seeing persons with dementia in outpatient, inpatient, and long-term care settings have need for a single reference that places the dementia syndromes in the perspective of world health and provides information ranging from day-to-day management to the pathophysiology of the multiple causes of the dementia syndrome.

This edition, brought together by the able work of Myron F. Weiner, is a tribute to his long career in clinical care and research in everything Alzheimer. Dr. Weiner has made significant contributions to the treatment of Alzheimer disease, management of behavioral symptoms, and understanding the psychological consequences of dementia and its impact on caregiving. Further, he has worked to identify antecedents of the dementing illnesses such as the impact of cardiovascular risk factors in the development of Alzheimer disease, and he has contributed to raising the awareness of the disease in underserved populations.

This sensibility is apparent as one reads through this volume for which he and co-editor Anne Lipton have assembled a group of contributors who are themselves practitioners and clinical researchers dealing with dementia patients each day. They represent international efforts and knowledge with expertise in the complex ethical issues of dealing with dementia, a global awareness of diagnosis, and treatment and management of the disease. The content of this volume reflects a most comprehensive review of cognitive, functional, behavioral, and social aspects of the disease and addresses the interaction between psychopharmacological and behavioral/environmental approaches to disease management.

In the pages that follow, the reader will find important details about state-of-the-art diagnostic methods, including the importance of the probing clinical interview, the value of the medical evaluation, the utility of neuropsychological testing, and the use of current imaging techniques. The current knowledge in these areas allows us to diagnose subtle syndromes such as mild cognitive impairment, and while this entity has significant heterogeneity, there is irrefutable evidence from prospective trials that careful characterization can foreshadow a diagnosis of Alzheimer disease. It is truly a revolutionary idea that we have the potential to predict this progression. The reader will also find that the breadth of cognitive impairment can be quantified allowing for the characterization of a vascular cognitive impairment, sometimes subtle and diffuse, but with significant public health consequences. The hope for newer imaging technologies is described with the goal of having the ability to diagnose earlier, discriminate among disease entities, track subtle change, and provide markers of treatment effect.

As the field of dementia research has progressed, our understanding of different entities has grown, initially focusing on clinical and neuropathological distinctions of frontotemporal dementias and conditions associated with Lewy bodies. Each of these dementias has come under considerable study with many efforts to establish and revise consensus criteria as new information has come forward. These global efforts ensure a common language to describe serious conditions and lay the foundation to systematically study treatments and management for each.

In fact, starting with the earliest efforts to create research criteria for Alzheimer disease, the field has made remarkable strides in developing treatments. It should be recalled that less than 20 years ago there were no approved treatments, and while the search for more effective treatments and cures goes forward, the Alzheimer patient of today can expect to be offered one of several drugs approved for the treatment of their disease. Approval for the treatment of other dementias has been made possible by the establishment and recognition of diagnostic criteria and development of sound clinical trial design.

The significant behavioral and psychiatric disturbances of dementia are now well acknowledged, leading to important research efforts in treating and managing these manifestations. The sections of this volume offer the most comprehensive and current view of treatment options and describe both pharmacological and nonpharmacological interventions. As the reader will find, the challenge of addressing these aspects of dementia is great, as is their social and economic impact. Further, the molecular pathology of these syndromes has been elucidated, allowing us to speak of such entities as amyloidopathies, tauopathies, and synucleinopathies and create new ways to understand and potentially attack these diseases.

The dissection of the molecular pathways to the accumulation of amyloid, tau, and synuclein is one of the most exciting advances in dementia research because it provides targets for future interventions. Though it is not yet yielding cures, this line of research has reached the level of clinical trials with both positive and negative results guiding the next step.

As we develop more effective treatments, the needs of those who are afflicted and those who care for them must be addressed. sections on approaches to family support and dealing with the dilemma of losing independence through an ethical and legal framework provide critical information that will serve the clinician well. Rigorous research to fill in the gaps of knowledge about patient choice and decision making is ongoing and will maximize the quality of life for current and future generations of patients.

The contributors to this volume indicate that the ultimate aim from a public health and personal choice perspective is prevention. The final section provides thoughtful discussion of the future of dementia. The complex details of current technologies in biomarkers, molecular biology, and drug development for both cures and prevention are presented in a clear and understandable way, to be approachable for both clinician and scientist. Models of disease prevention, through both lifestyle modification and pharmacology, are discussed and evaluated.

This volume provides tools for caring for those with dementia now and hope for those facing it in the future. It will form an important part of the professional library of the psychiatrist of the future.

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