International Psychogeriatric Association Please Join Us Geriatric Psychiatry in the 21st Century: A Global Perspective Jacobo Mintzer M.D. Executive Director Roper Saint Frances Clinical and Biotechnology Research Institute Professor of Health Sciences Medical University of South Carolina and Staff Physician Ralph P Johnson Veterans Medical Center, Charleston S.C. USA Past President International Psychogeroatric Association 1 Percentage of Growth for People Over 65 Years of Age Dependency Ratio Source: Dept for work and Pensions UK Source: National Bank Denmark The dependency ratio measures the % of dependent people (not of working age) / number of people of working age (economically active)
EURO GDP Balancing Budgets? Increase in Health Care Costs More Issues of Concern Most countries do not have a structured training in geriatric mental health in any discipline Most countries do not have a public policy agenda in geriatric mental health NO country has the resources to manage geriatric mental health needs
A Concrete Example Eli Lilly s Solanezumab will earn Decision Resources Proprietary Clinical Gold Standard Status for the treatment of Mild to Moderate Alzheimer s Disease. The total Alzheimer s Disease Drug Market will nearly triple, increasing from $5.4 Billion in 2010 to $14.4 Billion in 2020, according to findings from Decision Resources Christopher Comfort Decision Resources Group781-993-2597ccomfort@dresources.com 10 Memantine in Moderate to Severe AD Study Results: Cognition SIB The Solution is in the Spaghetti The Memantine Group Exhibited Significantly Superior Cognitive Function Compared With the Placebo Group Mean Change From Baseline in SIB Score 2 0-2 -4-6 -8-10 -12 P=.068 Memantine Placebo P<.001 P=.002 P<.001 0 4 12 28 End Point Week n = 126 119 107 96 126 n = 126 117 106 83 126 OC analysis. LOCF analysis Adapted with permission 2004 from: Reisberg B, Doody R, Stöffler A, Schmitt F, Ferris S, Möbius HJ. N Engl J Med. 2003;348:1333-1341. Copyright 2003 Massachusetts Medical Society. All rights reserved. Improvement Deterioration
The Solution is in the Spaghetti The Vision of a Futurist The 21st century will be about massively providing highly individualized products. Ted Gordon AAGP 2000 The Geriatric Mental Heath Hypothesis The impact of Pharmacogenetics and Biomedical Research in Clinical Practice The challenge for geriatric mental health in the 21st century is to provide care for the many with attention for the individual We need to provide massive amounts of individualized care Without breaking the bank!!! Drug discovery research Identify new disease susceptibility genes Identify new disease mechanisms Identify new therapeutic targets Drug development Stratification of disease Select patients most subgroups (better diagnosis) suited to therapies Correlate genotype with disease progression Correlate genotype with drug efficacy, safety and metabolism (dosage) Predict responders and non-responders to a drug Drug marketing Cost effective health care management
What Do I Mean? Risperdal in the treatment of psychosis and aggressive behavior in dementia The average risk to develop a stroke or a cardiovascular condition over a ten year period for a 57 years old man is 7.4% The use of Cholesterol lowering treatments can reduce the risk by 30% or over 2 points. The medications however have potential severe side effects My personal risk is 2.4%. In my case, even if I had high cholesterol, the treatment will only reduce my risk by 0.8 points. Mean change from baseline BEHAVE-AD Aggressiveness Score Weeks of therapy 1 2 3 4 6 8 10 12 Endpoint Katz, Jeste, Mintzer et al. J Clin Psychiatry 1999; 60: 107 15. Risperidone in the treatment of psychosis and aggressive behaviour in dementia: % of patients with adverse events FDA Warning Events (>10%) EPS Somnolence Agitation Falls Edema, peripheral Injury Pain Placebo n=163 7.4 7.4 10.4 19.0 5.5 37.4 8.0 0.5 mg/d n=149 6.7 10.1 7.4 16.1 16.1 32.9 6.1 1 mg/d n=146 12.8 16.2 5.4 12.8 12.8 28.4 2.7 2 mg/d n=185 21.2 27.9 7.3 24.2 18.2 32.1 10.9 An FDA meta-analysis of 17 placebocontrolled clinical trials (n=5,106) of 4 atypical antipsychotics (aripiprazole, olanzapine, quetiapine, and risperidone) in elderly patients with dementia-related psychosis revealed a pooled 4.5% incidence of mortality for atypical antipsychotics versus 2.6% for placebo Katz, Jeste, Mintzer et al. J Clin Psychiatry 1999; 60: 107 15. FDA April, 2005
Risperidone in the treatment of psychosis of Alzheimer s disease: Results from a prospective clinical trial CATIE Mean (± SE) change from baseline over time in BEHAVE-AD Psychosis subscale score. Pla = placebo; Ris = risperidone; SE = Standard Error. Mintzer,2006 Schneider, L 2006 Mean Efficacy 18 1 71 61 15 13 4 12 11 10 9 8 7 Behave-AD Over Time Low-agitation Placebo High-agitation Placebo Low-agitation Risperidone High-agitation Risperidone 6 Baseline1 2 3 4 6 8 10 12 Endpoint Time (Weeks) Mintzer, APA AGT:P < 0.05 vs. Placebo. 2004 Non-AG: P< 0.05 vs. Placebo. Dementia CMAI Scores: High and Low Agitation Groups Mintzer J et al. ACNP 2005.
Adverse Events By Level of agitation Mintzer J et al. ACNP 2005 The Antipsychotic Discontinuation in Alzheimer Disease Trial Research studies on the effects of discontinuing antipsychotic medications in patients with dementia have not identified specific target symptoms or response to antipsychotics prior to discontinuation Current available regulations require antipsychotic discontinuation every 6 months The Antipsychotic Discontinuation in Alzheimer Disease Trial Randomization of responders to open treatment Patients who met criteria for response at 16 weeks: 30% decline in NPI core scores with CGI-C score of 1 (improved) or much improved (2) rated on psychosis/agitation only Double-blind randomized phase 110 of 112 responders were randomized Risperidone:Placebo 2:1 ratio from 16-32 weeks Randomization stratified by presence / absence of psychosis, outpatient / assisted living or nursing home Risperidone (0.25 to 3 mg daily) maintained at end-open treatment phase dose (mean 0.97 SD 0.74 mg per day) into the randomized phase
Relapse in final 16 weeks after randomization Both time to relapse and risk of relapse favored risperidone over placebo Survival analysis: log-rank test Relative Hazards ratio: 4.88, 95% CI 1.08-21.98, p=0.023 Relapse rates 48% (13/27) relapsed on placebo 15% (2/13) relapsed on risperidone Chisq=4.33, p=0.017 Action Plan Achieving global recognition of geriatric psychiatry as a subspecialty. Promotion and accreditation of national or international education programs. Both 16-week time periods: no effect of nursing home/outpatient or psychosis status LIA FERNANDES, 2015 Action Plan Promotion and financing of international exchange of geriatric psychiatry programs (at graduate and postgraduate levels). Collaboration on international research networks, particularly with IPA affiliates, the EAGP, and the WHO. Helping the affiliate organizations in countries with less developed psychogeriatrics, with support of research funding (e.g. grants and fellowships). Promotion of research in geriatric psychiatry with projects possibly led by IPA and aiming for identification of the best patient for the best treatment at the best time. Action Plan Sharing with former pioneers references, the expertise for consultation and education in local trainings. Participation of international opinion leaders in education and scientific conferences, continuing medical education (CME) programs, subspecialty training courses, and online education. IPA should act as an international leader in psychogeriatrics in international forums related to mental health of the elderly. Advocacy to influence the political process to improve mental health services for older people and strengthen national associations and their members with financial support LIA FERNANDES,2015 LIA FERNANDES
Conclusion We need to have the right professionals find the right patient and provide: The right treatment/medication At the right time At the right dose