Towards a WPA Position Document on the Human Rights of Older Adults with Mental Health Conditions

The increasing number of older adults in countries across the world is a huge challenge to those that are in charge of promoting, protecting, and implementing their human rights. This task is particularly difficult in the absence of a strong international framework addressing the principles required to guide the actions to combat all human rights violations. The existence of such a specific framework for older adults with mental health conditions is justified in view of the particular vulnerability of this section of the population by virtue of societal ageism, stigmatization, exclusion, as well as the disability and dependency which mental health conditions in old age may confer. The present article is a development of a previous statement by the International Psychogeriatric Association and the World Psychiatric Association Section of Old Age Psychiatry. As there is a call to all organizations to support efforts to combat Human Rights violations among older adults, a text will be submitted to the Executive Committee of the World Psychiatric Association to approve an official position statement on Human Rights of Older Persons with Mental Health Conditions.

The Evolution of Diagnostic Boundaries of Alzheimer’s Disease and Novel Therapeutic Options

Over the past three decades, the definition and diagnostic boundaries of Alzheimers disease (AD) have been repeatedly revised due to significant progress in understanding of the pathogenesis of neurodegeneration associated with Alzheimers disease and in the development of high-tech diagnostic methods. The current approach to AD diagnostics relies on the detection of biomarkers that reflect two main neuropathological processes involved in the primary neurodegeneration that underlies AD: abnormal amyloidogenesis, and neuronal degeneration. The currently available diagnostic tools are limited to the detection of cerebrospinal biomarkers and/or assessment of the abnormal amyloid and tau protein burden in the brain via amyloid and tau positron emission tomography (PET) ligands. Practical implementation (mostly in the research field) of the biological model of AD diagnosis has led to a significant expansion of its diagnostic boundaries with the inclusion of predementia AD stages: asymptomatic and symptomatic, the latter is clinically corresponding to amnestic mild cognitive impairment (aMCI-amnestic mild cognitive impairment). On the one hand, this approach significantly expands the possibilities to study and use preventive technologies aiming to avert or delay the progression of predementia cognitive impairment to dementia but, on the other, it is associated with a number of negative implications from both the clinical and ethical points of view. A significant limitation of purely biological diagnosis of AD based on biomarker levels is due to the low prognostic value of biomarkers, which can cause diagnostic confusion in certain circumstances. Moreover, since the future evolution of the asymptomatic stage is not yet clear and there are still no reliable ways to prevent the cognitive and behavioral symptoms associated with AD, disclosure of stressful information about this terrifying diagnosis to patients can cause irreversible damage by triggering depressive disorder, which is a risk factor of AD itself. The current knowledge about AD prognosis in amyloid-positive cognitively unimpaired patients is insufficient.The most adequate approach to early AD diagnostics appears to be the clinical and biological model, as recommended by the International Working Group (IWG 2021), which requires a combination of the clinical AD phenotype and the detection of biomarkers specific to this disease. The article discusses the potential directions for the development of biological diagnostic methods, including those based on the so-called peripheral (serum) biomarker technologies and promising directions for the development of biological methods of secondary AD prevention.

Cerebrolysin in the therapy of mild cognitive impairment and dementia due to Alzheimer's disease: 30 years of clinical use

Alzheimer's disease (AD) is the most common neurocognitive disorder and a global health problem. The prevalence of AD is growing dramatically, especially in low- and middle-income countries, and will reach 131.5 million cases worldwide by 2050. Therefore, developing a disease-modifying therapy capable of delaying or even preventing the onset and progression of AD has become a world priority, and is an unmet need. The pathogenesis of AD, considered as the result of an imbalance between resilience and risk factors, begins many years before the typical clinical picture develops and involves multiple pathophysiological mechanisms. Since the pathophysiology of AD is multifactorial, it is not surprising that all attempts done to modify the disease course with drugs directed towards a single therapeutic target have been unsuccessful. Thus, combined modality therapy, using multiple drugs with a single mechanism of action or multi-target drugs, appears as the most promising strategy for both effective AD therapy and prevention. Cerebrolysin, acting as a multitarget peptidergic drug with a neurotrophic mode of action, exerts long-lasting therapeutic effects on AD that could reflect its potential utility for disease modification. Clinical trials demonstrated that Cerebrolysin is safe and efficacious in the treatment of AD, and may enhance and prolong the efficacy of cholinergic drugs, particularly in moderate to advanced AD patients. In this review, we summarize advances of therapeutic relevance in the pathogenesis and the biomarkers of AD, paying special attention to neurotrophic factors, and present results of preclinical and clinical investigations with Cerebrolysin in AD.

Cerebrolysin for vascular dementia

BACKGROUND

Although vascular dementia is the second most common cause of dementia globally, evidence-based treatments are still lacking. Cerebrolysin is a porcine brain-derived preparation that is said to have neurotrophic and neuroprotective activity. In many parts of the world Cerebrolysin, given as a series of daily intravenous infusions, is used as a potential intervention for vascular dementia. A previous Cochrane Review on Cerebrolysin in vascular dementia yielded inconsistent results. We wished to update the review to add new studies from the international literature and employ contemporary methods for appraising the strength of the evidence. This is the first update of a review first published in 2013.

OBJECTIVES

Primary: to assess the effect of Cerebrolysin on cognitive function, global function, and all-cause mortality in people living with vascular dementia. Secondary: to assess the adverse effects of Cerebrolysin and to assess the effect of Cerebrolysin on quality of life and caregiver burden.

SEARCH METHODS

We searched ALOIS, MEDLINE, Embase, PsycINFO, CINAHL, ISI Web of Knowledge, LILACS, the Cochrane Library, ClinicalTrials.gov, and the WHO ICTRP on 16 June 2017, 9 May 2018, and 9 May 2019. We expanded the search by adding four Chinese databases, searched from 1 January 2012 to 19 May 2019. We checked bibliographies of relevant papers identified and contacted pharmaceutical companies, trial authors, and experts in the field to identify any additional published or unpublished data.

SELECTION CRITERIA

We included all randomised controlled trials of Cerebrolysin used in people living with vascular dementia. We applied no language restriction.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials for inclusion and evaluated their methodological quality. Data were extracted and analysed using mean differences (MDs) or standardised mean differences (SMDs) with 95% confidence intervals (95% CI) for continuous outcomes. We reported dichotomous outcomes as risk ratio (RR) with 95% CI. We assessed the strength of the available evidence using the GRADE approach.

MAIN RESULTS

We identified six randomised controlled trials with a total of 597 participants that were eligible for inclusion in the 2013 review. No new studies were eligible for inclusion in this update. Participants in the included studies, where dementia severity was reported, had mild to moderate severity of vascular dementia (four trials). The included studies tested varying doses and duration of Cerebrolysin treatment. Follow-up ranged from 15 days to three years. Five of included studies were conducted in China (three studies), Russia (one study), and Romania (one study), while relevant information of other study was unclear. Where details of funding were available, all studies were supported by the pharmaceutical industry (three studies). Cognitive function was measured using the Mini-Mental State Examination (MMSE) or Alzheimer's Disease Assessment Scale Cognitive Subpart, extended version (ADAS-cog+). Combining the MMSE and ADAS-cog+ data (three studies, 420 people), there was a beneficial effect of Cerebrolysin (SMD 0.36, 95% CI 0.13 to 0.58; very low-quality evidence). Global function was measured by Clinician's Interview-Based Impression of Change plus Caregiver Input (CIBIC+) or Investigator's Clinical Global Impression (CGI). We assessed response rates on these measures (the proportion of participants with a CIBIC+ score of < 3; or at least moderate improvement of the CGI rating at the last visit). There was a beneficial effect of Cerebrolysin (two studies, 379 participants, RR 2.69, 95% CI 1.82 to 3.98; very low-quality evidence). Only one trial described mortality and reported no deaths. Four studies reported adverse events; data from two studies (379 people) were in a format that permitted meta-analysis, and there was no difference in rates of adverse effects (RR 0.91, 95% CI 0.29 to 2.85; very low-quality evidence). No studies reported on quality of life or caregiver burden.

AUTHORS' CONCLUSIONS

Courses of intravenous Cerebrolysin improved cognition and general function in people living with vascular dementia, with no suggestion of adverse effects. However, these data are not definitive. Our analyses were limited by heterogeneity, and the included papers had high risk of bias. If there are benefits of Cerebrolysin, the effects may be too small to be clinically meaningful. There have been no new studies of Cerebrolysin in vascular dementia since the last Cochrane Review. Cerebrolysin continues to be used and promoted as a treatment for vascular dementia, but the supporting evidence base is weak. Adequately powered, methodologically robust trials are needed to properly assess the effects of Cerebrolysin in vascular dementia.