We learn most from the patients we treat, rather than the books we read.
Collections of case histories attempt to foster learning by simulating the experience of assessment and treatment. The success of any such publication is thus its ability to engage the clinician learner, stimulate analytical thought and provide incisive information sufficient to both educate and inspire reflection. The reader must find the cases relevant, the discussion erudite, the information well researched and take that which has been learned to the clinical coalface for the book to have succeeded.
The series editors note the Oxford Case Histories series aims to provide more complex case-based learning in aiding preparation for clinicians in specialist training and consultants’ whilst the editors of this volume state that as a result of the aging population, the ‘demand for generalists expert in the care of complex older patients is. . .likely to continue to rise over the coming decades’. Thus, this volume seems to be aimed at both specialists in geriatric medicine and at upskilling generalists, who after all will find that older people make up a significant portion of their practice: aims that are seemingly at odds.
The book comprises 48 cases covering a diverse number of presentations and geriatric issues ‘selected to illustrate the wide spectrum of acute medicine in older patients’. Each is a clinical vignette accompanied by appropriate investigation findings after which is posed a series of questions for the reader to consider covering diagnosis and management, incorporating ethical and broader aspects of care. Each of the questions is then discussed, with evidence (or acknowledgement of the paucity thereof) provided for the responses. For some of the cases progress and subsequent clinical conundrums are presented.
Rather than classify the cases by symptom presentation or by ‘geriatric syndrome’, many of the cases relate to specific etiologies: motor neuron disease, heat stroke, coeliac disease and AIDS/syphilis, for example. The usual suspects are there too: delirium, dementias and elder abuse, but only fecal incontinence rates a mention, its urinary cousin seemingly absent from the case list. It is an interesting list, which clearly has its origins in the experience of the authors. Some of the cases feel as though they are more simply presentations of pathology in older people (some of the patients have only just reached retirement age!), although this does on occasion allow for discussion of atypical presentations and management considerations in this patient group.
Not surprisingly, the book is strongest when dealing with the conditions most associated with aging. The chapter on delirium is comprehensive, though sadly the DSM definition was updated while the book was gestating. The well thought out discussions of elder abuse, advance care planning and decision-making capacity are valuable for all clinicians, since these are common issues with which many struggle. The cases of dementias are practical and serve to differentiate several of the major causes in a way that non-specialists could find valuable. The section on sexuality and the risk of sexually transmitted infections in older people covers an area that is frequently overlooked.
The cases read well, although the investigations could be presented in an easier to digest format and with greater uniformity. Naturally, some of the legal details relate to the British system and there is little to guide readers from other geographic locales. As with most medical writing, the cases tend towards the dry. At best, we get a little insight into the person with the problem and how that might affect diagnosis and management. What is missing is the individuality – crooked smile, lilting voice, sports fanaticism – that helps lock down our memories and thus our learning from the real patient in front of us.
So, have they achieved their aims? There is certainly knowledge to be gained here for trainees in Geriatrics, and the exercise in working through the cases should prompt reflection on the patients they have treated. Geriatricians will likely gain less in the way of new information but might be prompted to wonder just how many cases of intravascular B cell lymphoma they have missed. How useful is this book for generalists? The required information for the assessment of common problems in older people is here, but the generalist might struggle to assimilate this in amongst the more rare and wonderful of disease presentations. I would recommend it to advanced trainees in Geriatrics but I'd need to highlight specific cases if I was to recommend it for anyone else looking for a good grounding in geriatric medicine.
