-

IPA Bulletin

Aging in a World of Change - Eighth Congress Jerusalem, August 17-21, 1997

Leon Flicker

The Congress opened on an informal note with a gathering in the Holiday Inn Crowne Plaza, where we learned that our meeting coincided with the Israeli festival of love, the equivalent of St. Valentine’s Day.  The only impact of this occurrence was the inability of delegates to use any of the hotel pools, as they were in constant use as a backdrop for weddings during this period!

The scientific program began with the observation that the setting of the conference in Jerusalem imbued the meeting with a spirituality that was unsurprising in the birthplace of three of the world's great religions.  The conference organisers, Drs. Belmaker and Davidson,  welcomed the delegates and it was clear that their complementary skills would ensure a successful meeting.

Professor Raymond Levy astutely announced that he would be unable to explain the causes of the many difficulties inherent in performing psychogeriatric research in his brief remarks, and referred the delegates to a previous editorial on this subject.  He then proceeded to have fun and instructed the delegates to do likewise.  Delegates concerned that Professor Levy would lack direction in his retirement were pleased to learn of his determination to discover which of the world's great historical figures actually had fun.

Delegates were then treated by Professor Norman Sartorius to a masterful exposition of the sociological and human context to many of the problems confronting those who care for the elderly.  The possibility of increasing generational conflict has never been higher, and the next few years may see increased pressure on services as older people will have to unite to maintain adequate facilities for those most impaired.

The papers presented by the three winners of the 1997 IPA/Bayer Research Awards in Psychogeriatrics covered a broad spectrum of the psychiatric disorders of old age.  They addressed the prediction of treatment-resistant depression by organic pathology (Steve Simpson), the association of behavioral disturbance with increased caregiver burden (Michel Bédard), and the pervasiveness in the very old of the wish to die (Michael Linden).

An innovation at this conference was provision of sponsored lunches accompanied by presentations.  The first of these outlined the development of a new cognitive screening instrument.  Some in the audience remained unconvinced of the need for another such screening test, questioning the potential deleterious effects of widespread screening.  The second presentation dealt with a clinically sensible way of assessing response to treatment with anticholinesterase inhibitor medications, while the third dealt with current and future strategies in the pharmacological treatment of people with Alzheimer's disease.

A fascinating presentation by Copeland and Holmes addressed the interface between epidemiology and neuropathology.  Their message was that neuropathology coupled with epidemiology provides increasing evidence of mixed pathology rather than pure forms of dementia, particularly in the oldest old.  This session was complemented by another on frontal lobe dementia, which revealed the increasing importance of the diagnosis of this condition, both in neuropathological and clinical terms.  In particular, behavioral management strategies based on neuropsychological abnormalities may be particularly valuable.  It was refreshing to hear health economists explain the current technical limitations of their science as it applies to dementia, and the increasing need for basic research before definitive studies can be performed.

Professor John Breitner maintained the high quality of the plenary lectures with a fascinating talk on genetics and epidemiology of Alzheimer's disease.  Twin and family studies, in this condition and others, are a powerful method used to unravel the effects of environmental and genetic factors.  Recent evidence was presented highlighting a wearing off of the effect of ApoE Î4 with advancing age, perhaps also sex dependent.  The possible beneficial effects of H2 blocking agents and nonsteroidal anti-inflammatory drugs were discussed, although the epidemiological evidence is not particularly strong yet.  The thorny issue of whether Alzheimer’s disease is a separate condition or represents the end of a continuum with normal aging was raised in question time; it was agreed that the current level of disagreement should continue!

A session on advances in cholinergic therapies for the treatment of Alzheimer's disease heralded the most dramatic change occurring in recent IPA conferences.  There is now abundant evidence that the new anticholinesterase drugs work for some of the cognitive symptoms of Alzheimer's Disease.  As in most biological systems, different types of anticholinesterases have been identified, and the potential for tailoring drugs to inhibit these subtypes was briefly discussed.

The hypothesis of differential effects and side-effects of the cholinesterase inhibitor drugs versus the muscarinic agonists was also presented.  Although these agents have relatively modest effects, they represent an exciting new avenue for the active treatment of people with dementia.  A later symposium was again dominated by the development and evidence of efficacy of the cholinesterase inhibitor drugs.

A session on steroid hormones and CNS in aging also was valuable.  Changes with aging were described in the subtypes of the cytochrome P450 system as well the circadian rhythm of the hypothalmic-pituitary-adrenal axis.  The evidence for the cognitive sparing effect of estrogen was reviewed systematically and found to be extraordinarily weak considering that there are many who advocate the use of estrogens in the prevention of Alzheimer's.  This is an area where belief can far outstrip the availability of evidence.

The Wednesday morning plenary pleased those who believe that dogmatic assumptions should be investigated by scientific rigor.  This time, Dr. Michael Davidson treated the delegates to an extraordinary exposition on cognitive impairment in schizophrenia.  In many parts of the world there has been a policy of deinstitutionalisation which, in reality, has been a process of transinstitutionalisation, effectively mainstreaming the accommodation of people with psychiatric disability.

Professor Davidson demonstrated evidence that the cognitive decline, in the order of two points in the MMSE per decade of illness, is probably biological in nature and unrelated to the sensory deprivation of institutional settings.  Unfortunately, many of the remaining institutionalised patients are in fact the group who have exhibited the greatest amount of decline.  The neuropathology of this condition is probably not Alzheimer’s disease in the majority of cases.  Professor Folstein then provided some arguments that many of the symptoms of the agitated patient with dementia are similar to the diagnostic category of mania and may justify treatment in this regard.

An experiment with an interactive exercise followed morning tea.  The illustrative case represented a complex management and ethical dilemma in a man with paranoid delusions and behavioral disturbance.  In my view as a relative outsider (a geriatrician), the most amazing aspect of this exercise was the degree of concordance expressed in the views of psychogeriatricians from many countries around the world.  I can assure my psychogeriatrician colleagues the degree of consensus demonstrated was not in keeping with the view of psychiatrists held by other physicians!  Although this was a good session, I would suggest that such interactives are enhanced by computer touch screens in the selection of responses, as this minimises the influence of peers on the interaction process.  This is definitely a session that should be repeated at the next congress, perhaps to a larger audience with appropriate technical support.

A session on biological markers presented a potpourri of interesting tidbits, including a report on new process of functional brain imaging using infrared spectroscopy.  Not surprisingly, patients with Alzheimer’s disease exhibit differences from controls.  The findings of increased DHEA along with elevated cortisol in depressed patients raises questions on the utility of this hormone in the treatment of depression.  A method of detecting differences in free radical metabolism was presented, as was a study demonstrating an association between poor vitamin D nutrition, pain, and impaired cognitive state.  Altered zinc metabolism was also found in patients with Alzheimer's disease, although the pathogenic pathway for this association remains obscure.  The Eighth Congress emphasised the increased importance of the methods of the new genetics in understanding the pathogenesis of Alzheimer's disease.  Delegates were exposed to reports of a broad range of studies, including an approach to characterise the specific phenotype associated with ApoE subtypes and a look at an issue that is increasingly important about virtually any disease -- whether it is more appropriate to look for associations with candidate genes, such as ApoE status, or whether a transgenomic search to identify genomic markers is more cost-effective.  The latter approach has been taken in the UK and would undoubtedly benefit from international collaboration.

An elegant presentation followed, demonstrating that the known mutations do not explain the majority of cases of familial Alzheimer’s disease (FAD).  The importance of expert counseling in discussion with the families of people with FAD was highlighted in another presentation, although the need for specific clinics for this purpose did not seem justified.

The molecules of Alzheimer's disease were again addressed in the final plenary session, which succeeded in unifying the major recent molecular biological findings.  The plenary began with a clear exposition of the present competing theories based on ApoE, Tau, Beta A4, presenilin 1, and presenilin 2.  The possible interaction between these factors was neatly explained and the possible multiple targets for effective therapies represent an exciting challenge for the future.

Recently there has been progress in the development of instruments that are less sensitive to educational and cultural bias.  This is an important area of development, as the risk for dementia may be ameliorated by environmental factors peculiar to populations that have not adopted a developed western lifestyle.  Only careful prevalence studies coupled with elucidation of environmental factors will yield results.  The comparison of African Americans with native Africans may be particularly important, as it represents a wide exposure to environmental factors.  A session on cross-cultural studies highlighted the difficulties of performing prevalence studies of dementia in populations with limited education.

A presentation on genetic, family, and epidemiological studies highlighted the difficulty of obtaining adequate family histories for research.  In addition, the potential usefulness of CT and MRI degenerative changes for selected clinically  based research was emphasised.  Comparing psychiatric morbidity and mortality demonstrated again the difficulties of performing aging research in a cross-sectional manner and underscored the need for cohort studies spanning extended periods.  Interestingly, the last session on memory clinics around the world highlighted similarities rather than differences between their practices.  There is no doubt that the imminent availability of effective medications will increase the need for accurate and specific diagnoses of patients with mild dementia.

In summary, the consistent and general theme of the meeting was that assessment must be multidisciplinary and include both physical and psychiatric illness in its scope.  The importance of addressing caregiver issues and the appropriate utilisation of local services were key emphases in all the clinics. 

About the Author

Leon Flicker is a visiting fellow in the Division of Clinical Geratology, Nuffield Dept. of Clinical Medicine, The Radcliffe Infirmary, Oxford, UK

This article appeared in IPA Bulletin, Volume 14, Number 2