Ross McDonald, whose tightly written novels about the hard-boiled private eye Lew Archer lifted the modern detective novel to the level of literature, died of Alzheimer's disease Monday night in Santa Barbara, Calif. He was 67 years old. The writer, whose real name was Kenneth Millar, died in the Pine Crest nursing home. For more than three years he had been suffering from Alzheimer's disease, which causes devastating changes in the brain and progressive mental deterioration..
Albin Krebs, July 13, 1983
A bit over 2 decades ago this obituary in the New York Times caught my eye because it was the first time I had ever seen a report of a death attributed to Alzheimer's disease. Great progress had been made in the previous decade to advance the understanding that Alzheimer's was not a rare dementing illness of the presenium, but rather the most common cause of dementia in older adults. In those days and even beyond, physicians usually blamed dementia in the elderly on "hardening of the arteries." While that condition undoubtedly existed in many such patients, only unusually did it cause the cognitive problem. Today, we acknowledge that more than 4 million Americans are afflicted with Alzheimer's disease, and the most recent figures from the National Center for Health Statistics list it as the seventh leading cause of death in the United States. We have, indeed, made tremendous progress in our understanding of the conditions causing dementia, which will become clear in this issue of Continuum, fashioned under the leadership of Dr Jody Corey-Bloom.
You will discover that we have moved beyond the era of "lumpers," when we tended to believe that almost all elderly patients with dementia suffered not from the ravages of atherosclerosis, but from Alzheimer's disease (usually alone, but sometimes in combination with the effects of vascular disease). In this issue, a formidable group of expert "splitters" will address a variety of other conditions that cause significant cognitive impairment in older and sometimes younger patients, as well. Dr Douglas Galasko discusses dementia with Lewy bodies, a diagnosis that is often difficult because of symptom similarities to Alzheimer's disease; however, you will see that characteristic features can allow the distinction to be made in many cases. Drs Indre Viskontas and Bruce Miller explore the fascinating varieties of the frontotemporal lobar degenerations, further splitting this disorder into frontotemporal dementia, progressive nonfluent aphasia, and semantic aphasia. Dr Helena Chui and Ms Nancy Nielsen-Brown review the current role of vascular disease as the culprit in some cases of dementia. Normal pressure hydrocephalus (NPH) has long been of major interest to neurologists because making the diagnosis offers the rare opportunity to reverse the cognitive deterioration, as well as the other two components of the NPH symptom triad, gait disturbance and incontinence. Dr Neil Graff-Radford brings clarity to the still perplexing issue of determining the likelihood of success with ventricular shunting.
Before these less common dementias are discussed, Dr Ronald Petersen and Dr Martin Farlow discuss mild cognitive impairment (MCI) and Alzheimer's disease (AD), respectively. The relatively new, and still emerging, concepts of MCI are elucidated by, arguably, the concept's foremost spokesperson, and Dr Petersen cogently speaks for its importance both in our understanding its relationship to AD and in its potential for facilitating the development of treatments that may slow the progression of the disease process. Dr Farlow brings us up-todate on the current concepts of AD, including a thorough discussion of therapeutic issues. Understanding and treating dementing illness do not rest solely on recognition of the cognitive impairment. As Drs Liana Apostolova and Jeffrey Cummings enlighten us, the neuropsychiatric features of these disorders are equally important; their recognition and treatment are often critical determinants of the ability of these patients to receive continued care at home rather than in a skilled nursing facility. In the final chapter of this issue, Drs Jennifer Whitwell and Clifford Jack, Jr. review the progress made in the neuroimaging of the dementias, a rapidly advancing field that increasingly utilizes the potential of functional neuroimaging.
To supplement your learning from this issue of Continuum, don't miss the patient management problem designed by Dr Corey-Bloom and the multiple-choice questions and discussions composed by Drs Ronnie Bergen and Douglas Gelb. They will tremendously reinforce your educational gains. In addition, a thoughtful ethics discussion by Dr Joseph Kass addresses the common and thorny problem of a patient with dementia driving a motor vehicle.
With this issue of Continuum, Dr Adam Fleisher introduces a new streamlined version of Quintessentials (QE), the much-praised case-based tool for practice improvement. The previous format for QE served its purpose, but it was so time-consuming that many readers failed to take full advantage of it. We have now retained the key features of QE, but shortened it dramatically and provided direct links to the relevant portions of the Continuum text itself. This will become an even more useful tool in the months ahead as we will soon launch the online version of Continuum for individual subscribers. Remember, Maintenance of Certification is now a requirement of the American Board of Psychiatry and Neurology, and both QE and Continuum have been endorsed by the ABPN as useful tools for the successful achievement of both the lifelong learning and self-assessment components of that goal. Try them!
I end this preface on a sad note. As I was editing the proofs for this issue, I learned of the tragic death of Dr Leon Thal, one of the world's premier researchers in the field of Alzheimer's disease. Leon died when his single-engine plane mysteriously crashed in California on February 3. Leon and I were residents and junior attending neurologists at Albert Einstein in New York years ago, when such pioneers as Robert Katzman and Robert Terry spearheaded that institution's leadership in Alzheimer's research. Leon's passionate commitment to Alzheimer's disease was already evident at that time, and he ultimately followed those two giants to San Diego, where he eventually succeeded Dr Katzman as the chairman of the Department of Neurosciences at the University of California at San Diego. Our faculty chair for this issue, Dr Corey-Bloom, is a member of that department. Leon embodied the best qualities of the physician-scientist, becoming the leader of the Alzheimer's disease's clinical trialists' community through his development and administration of the Alzheimer Disease Cooperative Study. Recipient of many honors, Dr Thal was awarded the highly prestigious Potamkin Prize by the American Academy of Neurology in 2004. A consummate clinician, scientist, and administrator, Leon always retained his great sense of humor, insouciant informality, and passionate concern for the development of future neurologists and researchers. A cautious and punctilious pilot, Leon died while engaged in his other lifelong passion, flying his own small plane. I dedicate this issue of Continuum on the subject of dementia to Leon's memory. He will be sorely missed by all. Our deepest sympathy goes to his family, friends, and, particularly, to his wife, Donna.
Aaron E. Miller, MD