Managing Chronic Disease Edited by Rogers CS, McCue JD, and Gal P. Oradell, NJ, Medical Economics Books, 1987, 439 pages, softcover, $29.95
Chronic diseases/disabilities occur in about 15% of the general population, but in 66% of those 85 years old and over. Women suffer more from chronic diseases than men, but exhibit less morbidity. Sixty percent of all geriatric care is chronic care. Thus, any book discussing the management of chronic diseases ought to be welcome.
This book in particular acknowledges that academic textbooks may give unrealistic advice. In contrast, the reader is promised a careful comparison of currently published advice with the habits of experienced and thoughtful clinicians. When in doubt, though, the editors suggest to check a "standard compendium, such as the PDR." Including the three editors, there are 20 practicing clinicians who address the initial evaluation, therapy, and long-term management of 40 of the most common chronic diseases of the adult.
Thus, the book is divided into 11 major subdivisions. There are 4 chapters on general issues; 4 on neurologic diseases; 9 on cardiovascular diseases; 2 on pulmonary diseases; 2 on digestive diseases; 3 on renal and urinary tract diseases; 4 on metabolic diseases; 4 on musculoskeletal diseases; 1 on cancer; 4 on psychological problems; and 4 on problems of aging. There is an extensive index, clear and descriptive references (about 10 per chapter), and an extensive use of tables and checklists.
Yet the book does not fulfill its promise. It is hard to find any comparison between "academics" and "practice." Some references are misspelled, and, since about 80% of adults afflicted with chronic diseases are geriatrics, one would have wished for more information on these patients. For example, in what the publisher calls "easy-to-scan" dosage schedules, little is said about geriatric dosing, and there are dosing schedules missing in such important areas as the management of behavioral pathology of Alzheimer's, a very important area of mismanagement of drugs.
The chapters are uneven, for example, the chapter on compliance is notable for its omissions. In the chapter on perioperative medical consultations, there is a suggestion that triceps skinfold thickness is useful for determining malnourishment in the elderly, a concept that has long been discarded. No other measure is suggested for establishing malnourishment in the elderly. This reviewer would also argue strongly that some of the concepts put forth in the chapter on Dying and Death are not in tune with modern practice. "Physician willingness to make occasional home visits correlates positively with successful management of terminal illness."
But then there is an excellent chapter reviewing epilepsy, and a very disappointing chapter on hypertension, which still suggests step-care as the best approach. Step-care therapy has been all but abandoned, since the clinician now has a range of options. It may still serve as a useful framework which must be modified to fit the individual patient. Any proposed antihypertensive therapy can now take into consideration the patient's sex, age, race, and concurrent diseases (and their treatment). Certainly, one should argue with the dosage range given for reserpine (0.125 50 0.25). It is curious that very little, if anything, is said about the management of isolated systolic hypertension, which of course is a larger risk factor in the elderly than elevated diastolic pressure.
This reviewer does not know when the chapters were written , but it now has been accepted for some time that calcium supplements in post-menopausal women do not address osteoporosis, and little, if anything, is said about problems of calcium supplements in the elderly with anactdity or hypochlorhydria. Also, in view of the fact that the nonsteroidal anti- inflammatory drugs are one of two classes of drugs whose use increases with age, the all too brief discussions of the potential for renal toxicity and gastrotoxiciry is disheartening. So are categorical statements as "anticholinergic effects are to be expected with all heterocyclics except trazodone," a statement many clinicians would dispute.
Insomnia, one of the great problems among nursing home patients, is given less than one page, with brief mention that short-half-life benzodiazepines and low dose tricyclics would be best. Yet, there is no discussion on the pronounced difficulty of withdrawing patients from long-term use of benzodiazepines, the problems being exaggerated when ultra-short acting benzodiazepines had been used.
Thus, while this may be a useful book on the diagnosis and treatment approaches to chronic diseases, it is difficult to recommend it to the practictioner "in the trenches."