Book Review: APA Handbook of Dementia

Book Review: APA Handbook of of Dementia

Anthony F. Tasso, PhD Fairleigh Dickinson University Chair, Department of Psychology & Counseling

Neurocognitive disorders are one of the most destructive and life-altering ailments, with the fear of developing dementia even surpassing the fear of a cancer diagnosis. At its worst, dementia, that includes vascular dementias, AIDS-related, Lewy body (LBD), frontotemporal, and of course, Alzheimer’s disease (AD) completely eradicates any semblance of the individual, wreaking havoc on the inflicted, as well as the loved ones forced to bear witness to the figurative, and eventual actual, disappearance. Even less severe neurodegenerative deficits have grave effects, resulting in significant quality-of-life issues undeniably interfering with one’s ability to love, work, and play.

With almost six million Americans currently diagnosed with some form of dementia, the emotional tab of these illnesses is immeasurable; although the annual Medicare and Medicaid tally comes in at an astonishing $160 billion (Alzheimer’s Association, 2016). The fact funding from the national Institute of Health for dementia significantly lags behind cancer and AIDS does not help, particularly as death rates from neurocognitive diseases are accelerating, adding further dread among the US population.

Given this increasing impact on the population at-large, the American Psychological Association (APA) published a comprehensive text on the broad domain of dementia. As part of the APA’s highly productive “Handbook series” (20-plus and counting), the nearly 700-page APA Handbook of Dementia (2018) provides wide-ranging assistance to psychologists by offering an overview of the extant empirical and practical literatures on neurocognitive disorders. Editor-in-Chief Glenn Smith brings together more than 70 pre-eminent scholars to plumb the breadth and depth of this most dreaded illness.

APA Handbook opens by discussing diagnostic criteria for dementia (e.g., declining cognitive functioning in at least two domains, including social abilities), as well Smith, G.E. (Ed.) (2018) Washington, DC: American Psychological Association.

as the non-linear progression of the disease, noting how 10-30% of individuals have neuropathological biomarkers (e.g., neuritic plaques, neurofibrillary tangles), yet do not exhibit discernable manifestations of the disease for decades, or ever. The text underscores how the apparent etiological x-factor is neuronal loss suggesting that AD and other dementias can lie dormant until the inflicted experiences a significant loss of neurons. APA Handbook outlines the data identifying upwards of 20 AD risk genes, with particularly attention to apolipoprotein E (APOE), and explains how Alzheimer’s is characterized by extracellular amyloid-B (AB) and intracellular tau deposits. The text explicates two types of Alzheimer’s disease: hippocampal-sparing AD that affects more of the cortex and less of the hippocampus and has an earlier onset (mean onset 63 years-old). This subtype is on contrast with the more limbic-based, hippocampus-focused AD, with a mean onset of 76 years-old. APA Handbook describes the common trajectory of AD’s presentation, with the typical first stage comprised of anterograde episodic memory, followed by impaired executive and attentional functioning along with possible deterioration in semantic and visuoperceptual capabilities. This contrasts Lewy Body Disease that is characterized by more motoric symptomatologies concurrent with cognitive decline, with neuronal loss experienced in the substantia nigra, caudate, and putamen with a concomitant underfunctioning of dopamine.

APA Handbook devotes a separate chapter to the assessment of the different dementias beginning with Alzheimer’s Disease that accounts for 60-80% of all dementia cases and affects 11% of people 65 and over and those numbers increasing to 32% for those 85 years old and older. As the sixth leading cause of death, APA Handbook highlights factors associated with AD pathology (e.g., neuronal atrophy, synapse loss, abnormal accumulation of amyloid plaques and neurofibrillary tangles in the limbic structures and cortices). The text also examines AD’s clinical presentation: episodic memory impairment, followed by impaired memory consolidation and encoding that creates difficulty in transferring newly learned information into longer-term memory. It is later characterized by diminished semantic memory and compromised use of language, eventually giving way to executive functioning deficits. The text identifies how Lewy body disease and Parkinson’s disease both follow a similar progression, although they vary in severity that has a subset of investigators hypothesizing that the two diseases represent different stages of the same underlying pathology rather than disparate conditions. Frontotemporal dementia (FTD, or Pick’s disease) is the third most common neurodegenerative dementia (behind Alzeimer’s and Lewy body) and is denoted by its early onset, with a mean age of onset is 58 years old. APA Handbook overviews the clinical symptoms of FTD that include motor disinhibition, apathy or inertia, compulsatory behaviors, diminished executive functioning, and language deterioration. The book describes how strokes or even “minor” cerebral hemorrhages can lead to alterations in white matter, the likely cause of vascular dementia (VaD). APA Handbook addresses the pathogenesis of HIV-associated neurocognitive disorder (HAND) that is the virus’ ability to cross the blood-brain barrier and infiltrate the central nervous system. The book reports on the early accounts of HAND during the heyday of the AIDS crisis, first seen in a subset of men with AIDS demonstrating impaired abstract thinking, trouble with learning, and slowed cognitive processing. This disease has witnessed a significant reduction in symptomatology thanks to today’s more sophisticated HIV/AIDS treatments.

Traumatic brain injuries and subsequent longer-term neurological sequelae are studied by exploring chronic traumatic encephalopathy (CTE, now more commonly called trau-

matic encephalopathy syndrome, or TES) a concept cemented in today’s lexicon given the increased public attention born out of the systematic study of football and military-related injuries. APA Handbook examines data that reveal even subclinical assaults to the brain can result in greater vulnerability for neuropathology later in life such as amyotrophic lateral sclerosis (ALS), vascular, Alzheimer’s, and Parkinson’s diseases, as well as various psychiatric conditions (e.g., lability, impulsivity, suicide). The text discusses brain-imaging apparatuses (e.g., CT, MRI, PET) and how these increasingly powerful tools provide rich information on healthy and unhealthy neurological functioning, offer useful data on the clinical presentations associated with different dementia subtypes, and represent a potentially fruitful means of detection, treatment, and ultimately prevention. However, it does appropriately temper expectations by indicating that such tools currently are incapable of providing a formal neurocognitive diagnosis.

APA Handbook examines culture and dementia by first exploring African Americans’ elevated rates of ADs compared to older White Americans and taps into possible biological, socioeconomic, and psychological causes for these racial disparities. Spanishspeaking persons are examined with attention to the roles of cultural and language factors associated with healthy and unhealthy cognitive processes. The book also provides an overview of cognitive processes in older Chinese Americans, with data suggesting parallel rates of AD and vascular dementias between Chinese Americans and White Americans. The chapter concludes with a useful vignette illustrating the nuances of clinical work with a neurocognitively impaired Chinese American patient.

The tome reviews frequently used dementia assessment measures from mental status exams to the Montreal Cognitive Assessment, Washington University Dementia screening, and Frontotemporal Lobar Degeneration tests. This section also looks at the assessment of everyday aging and functionality, including standardized assessment measures, self- and informant-reporting, observational measures, and the sensitive differentiation between normal age-related cognitive decline and pathological decline. APA Handbook touches on ethics and the law by honing in on capacity and competency in adults with mild cognitive impairment, and explains how the former refers to a health care professional’s assessment and the latter a legal decision. This chapter punctuates the notion that cognitive impairment does not automatically equate incapacity or incompetency.

The text covers primary, secondary, and tertiary preventions by first explaining the concept of cognitive reserve, which is the observed disparity between the underlying neurological pathology and observable neurocognitive functioning. It should be noted that a considerable percentage of individuals that exhibit the underlying dementia characteristics at the time of death (e.g., neurofibrillary tangles, plaques) did not exhibit clinical signs of such pathology, even during their later senior years. APA Handbook explores plausible explanations, such as larger brains (hypothesizing these can withstand neuronal decline) and greater intelligence, to the more active protective variables of higher education (specifically literacy mastery), active leisure activities, bilingualism, and aerobic exercising (that stimulates hippocampal neurogenesis). The text explores additional controllable preventative factors, such as conscientiousness, social connectedness, and having a purpose in life, while depression, neuroticism, loneliness, and lacking purpose are identified risk factors. Also studied is nonpharmacological secondary prevention, targeting both those at risk and those already exhibiting signs of mild cognitive impairment (MCI). The book provides an overview of the research on cognitive remediation and memory compensation, with aggregate data suggesting their efficaciousness in enhancing cognitive functioning in healthy older adults and those with MCIs; however, it shows more spotty findings with more severely symptomatic patients.

APA Handbook tackles the delicate process of talking with a patient about their possible dementia diagnosis. As the evidence indicates that almost half of health care professionals avoid direct discussion of a cognitive impairment with patients or families, the book provides a clear three-step module for doing so, beginning with before disclosure (e.g., explaining the pros and cons of knowing vs. not knowing, who else they would want to know, preferred breadth and depth of information), during disclosure (e.g., use of easily understood language, pacing of information, asking for feedback), and after disclosure (e.g., followup assessment of comprehension, referrals). The book then outlines common comorbid psychiatric conditions starting with depression that afflicts more than 50% of those with neurocognitive disorders. Noteworthy (and complicating the differential diagnostic process) are the overlapping symptoms between the two conditions as well as how depression is frequently evident during the prodromal phase of dementia. The book delves into sleep problems, linked to dementia and also owning a bidirectional relationship with a host of emotional disturbances. The text reports on how sleep plays an intricate role in proactively clearing problematic substances in the brain such as amyloids, and underscores how the increased understanding of the intricacies of sleep pathology may serve as a vehicle into dementia etiology and intervention. APA Handbook also explores pharmacology management. With nearly 70% of people with dementia on at least one psychotropic medication, it accordingly reviews the roles of antipsychotics, antidepressants, anti-epileptics, and cognitive enhancers for those with neurocognitive ailments. It also examines support groups, the longest-standing modality of intervention for those with dementia, and explicates the nuances of educational programs for patients and caregivers.

With elder abuse garnering more professional and public attention, APA Handbook hones in on the disconcertingly high rates of family violence perpetrated against those with dementia, with plausible reasons being their increased vulnerability in concert with the frustration regularly experienced by caregivers. Person-centered care, anchored in the Montessori philosophy, is explored, with its ethos of appreciating a person’s idography, illuminating choices, underscoring abilities (as opposed to only deficits), and modifying the environment to maximize support all with an eye on how to help the individual with dementia experience the best quality of life. The text closes with a concerted focus on palliative care and how to help with end-of-life issues for those with dementia. It overviews how health care professionals can support those with dementia and educate caregivers on options. The book closes by exploring the oft-complicated bereavement process.

APA Handbook is packed with useful information on the biochemical processes, pathogenesis, dementia typologies, and associative factors, and it soundly incorporates clinical, neuropsychological, and neurological disciplines. It also discusses the various means of prevention and support. Although the dense neurochemical terminology and concepts may be a challenge for the non-biologically based psychologist, the reader has the ability to gloss over the more medically intricate material without missing key take-home messages. With contributing authors brilliantly covering the range of issues associated with neurocognitive ailments, APA Handbook of Dementia represents a sound, highly useful tool for today’s psychologist. ❖