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Darling, sugar-plum, the traditional terms of endearment seem so pedestrian next to “autobiography of an almond” and the 99 other pet names that Paul West had for his wife Diane Ackerman before a stroke left him with global aphasia. West is a novelist, Ackerman a poet and naturalist, both “word-besotted creatures”, and One Hundred Names for Love is Ackerman’s heartening but ultimately frustrating account of how the couple overcame West’s loss of language. Disorientated after the stroke, stuck in a “sensory warp” with his “immense cosmos of words” shrunk to the single syllable of “mem”, West was initially given a long-term goal of being able to communicate basic wants and needs with “about 80% accuracy”. For West, it meant humiliation and isolation. For Ackerman it was “no more Paul calling across the hallway, ‘Poet, what’s a word for…?’”—the end of the relationship as they had known it.

Their “word-drenched companionship” seemingly over, West and Ackerman embarked on the gruelling process of rehabilitation. As West’s brain slowly adapts and words start to bubble into his speech again, Ackerman plays the role of interpreter. Asked by his speech therapist how he is feeling, West answers “feel as like a rising just dust in ear”. With an ear trained for poetry and word play, Ackerman instinctively understands what he means—“your ear is feeling tingly?” she asks, and he nods in reply. Incredibly, West is eventually able to write again, and begins to translate his own aphasic utterances into what, by comparison, now seems like boringly plain English. “I wish they’d change their approach to painting”, he complains of a publisher after they send him an anthology, before quickly clarifying: “by which I mean use bigger print”.

West and Ackerman’s resilience, loving endurance, and eventual triumph are genuinely moving, but fi nding this

Autobiography of an almond

In any medical practice that includes older adults, forgetfulness is a common symptom, dementia is a widespread concern, and cognitive impairment is distressingly prevalent. Memory Loss: A Practical Guide for Clinicians is a concise, pragmatic approach to cognitive disorders by two accomplished dementia specialists: a neurologist and a neuropsychologist. The cohesive text is an appealing blend of personal experience and clinical anecdotes, and is supported by a fi rm command of the rapidly changing clinical literature. The writing is crisp, lucid and, above all, practice-oriented.

The scope is comprehensive but not encyclopaedic. The well organised text includes sections about assessment; diff erential diagnosis; treatment; behavioural management; and issues related to fi nance, legal aff airs, and contact with family members. There are also short chapters about common and uncommon disorders. The treatment section includes chapters devoted to approved and non-approved therapies. Each chapter begins with a summary, and didactic text is generously supplemented by useful tables, fi gures, and sidebars. The authors recommend that the reader begins with the introductory chapters about assessment and Alzheimer’s disease, and then consults the other chapters as needed. I would suggest that the chapter about mild cognitive impairment be added to the basic reading.

Budson and Solomon are especially adroit in identi-fi cation of controversies, knowledge gaps, and areas in which diagnostic criteria are ill-defi ned or diffi cult to apply

(eg, fl uctuating cognition in dementia with Lewy bodies). Readers are not abandoned without guidance; ambiguities are resolved by confi dent descriptions of personal approaches to specifi c situations.

Herein lies both a strength and weakness of this clinical guide. Physicians routinely practise beyond the confi nes of the demonstrably eff ective and the authors move comfortably within this murky terrain. Their wont is to acknowledge potential limitations but then to stretch the boundaries of evidence-based medicine. For example, routine use of PET imaging or single-photon emission computed tomography for dementia assessment before the age of 66 years and off -label use of cholinesterase inhibitors and memantine in several disorders seem overvalued. For many practitioners, the result could be ineffi cient use of health-care resources and excessive enthusiasm for unproven therapies.

However, Budson and Solomon fully meet the challenge of their subtitle: they have provided an eminently practical, accessible guide for internists and family doctors, for neurologists and psychiatrists not subspecialising in the geriatric niche of their specialties, and for other clinicians who assess and manage elderly people with cognitive symptoms and signs. The book is an incredible compilation of practical advice and, although not always evidence based, always presented in a coherent, even manner.

Victor W Hendersonvhenderson@stanford.edu

BooksDementia made easy

Memory Loss: A Practical Guide for Clinicians

Andrew E Budson and Paul R Solomon. Elsevier, 2011.

Pp 320. £34·64 ISBN 9781416035978.

One Hundred Names for LoveDiane Ackerman. W W Norton,

2011. Pp 322. £16·99. ISBN 978-0393072419

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www.thelancet.com/neurology Vol 11 March 2012 215

story among the froth and foam that make up so much of the rest of One Hundred Names for Love can be infuriating. Too often an elegant and insightful account of West’s progress through therapy, or a poignant recollection of the couple’s former life will be elbowed aside by a self-indulgent and superfl uous digression. Just one example: a bit of a hermit, in the early stages of his treatment West is annoyed by the constant to and fro of carers in his room. He found dinner parties unnerving we learn—“you never know whom you’ll get trapped next to”. But then follows

an excruciating anecdote about a dinner party they did enjoy, “Carl Sagan’s fi ftieth birthday party, where we sat across the table from…”, and you get the impression that any fellow diners of Ackerman’s will have heard this one a few times before. As inspirational as West and Ackerman undoubtedly are, One Hundred Names for Love is unfortunately about 100 pages too long.

David Holmesdavid.holmes@zoho.com

Coping with ambiguous loss As the world population grows beyond 7 billion and average life expectancy increases, more of us will end up caring for someone with a degenerative neurological disease such as dementia. Even if we escape what Pauline Boss describes as the “ambiguous loss” of someone close whom we love, we are bound to have contact with people aff ected by the disease, and those who care for them, in our working lives and in our communities. Ambiguous loss, a phrase coined by Boss herself, is an unclear loss; unlike sudden death, which removes the loved one from our lives completely, ambiguous loss means that a person we love is present in body but not in mind. We might end up living with a total stranger, albeit one we have loved, for many years. Without pretending that it is easy, or possible in every case, Boss teaches alternative ways to approach or think about problems and guides the reader through the many conundrums that a caregiver might face, such as how to cope with talking to someone who neither recognises you nor responds to your voice.

Pauline Boss is emeritus professor of Family Social Science at the University of Minnesota. She also works as a family therapist, and continues to teach and do research. She has written previous books about ambiguous loss and has also worked with families whose loved ones are physically missing, but not confi rmed dead, as happens in natural disasters or war. She has been personally touched by both real and ambiguous losses in her life, but the quotes and

stories that shape this book are often about patients who have inspired her.

She teaches in a clear and concise way, without preaching, with summaries and ideas for refl ection. At the end of the book is an extensive resources section, including websites and even fi lms. At times the references to prayer and faith seemed superfl uous, and could prove too much for an atheist reader; yet she does balance this with her scientifi c research, and years of listening to and learning from real people.

She takes common themes and shows the reader how to alter their way of thinking to cope with common problems faced by caregivers. This is not a standard self-help book, but a lesson in looking at problems from a diff erent perspective, fi nding hope where there is despair, and fi nding the human side in all of us when faced with the task of giving our love to someone who cannot give it back.

As a doctor, this book has changed the way that I consult with my patients who are caregivers, and it has taught me how to be a more holistic practitioner to those who have dementia. It is an invaluable resource once you realise that we will all, in one way or another, be touched by dementia and by those who live alongside it.

Emma Hillemmahill@doctors.org.uk

Loving Someone Who Has DementiaPauline Boss. John Wiley & Sons, 2011. Pp 179. €16.90. ISBN 978-1-118-00229-2