Adiposity, hyperinsulinemia, diabetes and Alzheimer's disease: an epidemiological perspective

Insulin resistance and pathological brain ageing

Sir Harold Himsworth's prescient observations 75 years ago have recently been expanded to include a clear relationship between insulin resistance and central nervous system function. Insulin is a master regulator of corporeal ageing in all known species, determining the rate and expression of ageing in multiple body systems. Thus, it is not surprising that insulin also plays an important role in brain ageing and cognitive decline that is associated with pathological brain ageing. Brain ageing is accompanied by reduced insulin effectiveness, either by an inadequate cellular response to insulin or by insulin deficiency attributable to reduced insulin transport across the blood-brain barrier. Age-associated brain insulin abnormalities may contribute to cognitive decline in ageing, as have been documented in older adults with Type 2 diabetes mellitus and hypertension. With more extreme pathology, brain insulin resistance may be associated with neurogenerative diseases such as Alzheimer's disease, and the condition which precedes Alzheimer's disease, known as amnestic mild cognitive impairment. In the following review, we discuss the mechanisms through which insulin resistance may induce or potentiate pathological brain ageing and thereby create a neurobiological environment that promotes neurodegeneration and associated cognitive decline. This topic is timely, given that insulin resistance-associated conditions such as diabetes and obesity have reached epidemic proportions. The prevalence of such chronic conditions, in combination with a rapidly ageing population, may result in a corresponding increase in the prevalence of Alzheimer's disease and other cognitive disorders. Fortunately, insulin resistance-associated conditions are amenable to both pharmacologic and lifestyle interventions that may reduce the deleterious impact of insulin resistance on the ageing brain.

The Aβ oligomer hypothesis for synapse failure and memory loss in Alzheimer's disease

Alzheimer's disease (AD) is the 3rd most costly disease and the leading cause of dementia. It can linger for many years, but ultimately is fatal, the 6th leading cause of death. Alzheimer's disease (AD) is fatal and affected individuals can sometimes linger many years. Current treatments are palliative and transient, not disease modifying. This article reviews progress in the search to identify the primary AD-causing toxins. We summarize the shift from an initial focus on amyloid plaques to the contemporary concept that AD memory failure is caused by small soluble oligomers of the Aβ peptide, toxins that target and disrupt particular synapses. Evidence is presented that links Aβ oligomers to pathogenesis in animal models and humans, with reference to seminal discoveries from cell biology and new ideas concerning pathogenic mechanisms, including relationships to diabetes and Fragile X. These findings have established the oligomer hypothesis as a new molecular basis for the cause, diagnosis, and treatment of AD.

The association of age with rate of cognitive decline in elderly individuals residing in supporting care facilities

OBJECTIVES

This study examines the effect of age on rate of cognitive decline in different stages of dementia, of nursing home and assisted-living residents.

METHODS

In this longitudinal study, the Mini Mental State Examination (MMSE) was used to measure rate of cognitive decline in subjects who were nondemented [Clinical Dementia Rating (CDR)=0; n=353], questionably demented (CDR=0.5; n=121), or frankly demented (CDR≥1; n=213) at baseline.

RESULTS

A generalized estimating equation was used to model the MMSE scores over time (mean follow-up 2.9±2.0 y). The generalized estimating equation model had the MMSE scores at successive follow-up time points as dependent variables and had linear and quadratic age, follow-up time from baseline, CDR at baseline, and all the interactions among them as independent variables, controlling for MMSE at baseline, sex, race, and education. The mean age of the entire sample was 85.2±7.4 years at baseline. There were no significant interactions of linear age effects with rate of cognitive decline. The analysis of interaction of quadratic age with rate of cognitive decline showed complex relationships: in the nondemented group, there was no substantial quadratic association of age with the rate of cognitive decline (P=0.13); in the questionable demented group, the oldest subjects declined relatively faster (P=0.02); and in the demented group, the youngest and oldest subjects tended to decline relatively less than subjects in the intermediate ages (P=0.07).

CONCLUSIONS

This study adds an additional aspect to the complexity of the association between age and rate of cognitive decline, showing that the direction and amplitude of this effect differs according to the stage along the course of cognitive decline.

Repositioning leptin as a therapy for Alzheimer's disease

The data from the initial clinical trials utilizing recombinant human leptin as an obesity therapy were published in 1998. Since then, numerous studies have been described which address dosage, safety and efficacy of leptin replacement for a variety of disorders with diverse patient groups, including pediatric and adult subjects. We review the current clinical trial data, demonstrate that leptin administration is safe for long term use in humans, and summarize reported cognitive benefits. The functions of leptin in neuroprotection and cognition have been largely overlooked. Accumulating data suggest a very significant application of leptin may be a therapy for Alzheimer's disease.

SAR studies of acidic dual γ-secretase/PPARγ modulators

A novel set of dual γ-secretase/PPARγ modulators characterized by a 2-benzyl hexanoic acid scaffold is presented. Synthetic efforts were focused on the variation of the substitution pattern of the central benzene. Finally, we obtained a new class of 2,5-disubstituted 2-benzylidene hexanoic acid derivatives, which act as dual γ-secretase/PPARγ modulators in the low micromolar range. We have explored broad SAR and successfully improved the dual pharmacological activity and the selectivity profile against potential off-targets such as NOTCH and COX. Compound 17 showed an IC(50) Aβ42=2.4 μM and an EC(50) PPARγ=7.2 μM and could be a valuable tool to further evaluate the concept of dual γ-secretase/PPARγ modulators in animal models of Alzheimer's disease.

Activity energy expenditure and incident cognitive impairment in older adults

BACKGROUND

Studies suggest that physically active people have reduced risk of incident cognitive impairment in late life. However, these studies are limited by reliance on self-reports of physical activity, which only moderately correlate with objective measures and often exclude activity not readily quantifiable by frequency and duration. The objective of this study was to investigate the relationship between activity energy expenditure (AEE), an objective measure of total activity, and incidence of cognitive impairment.

METHODS

We calculated AEE as 90% of total energy expenditure (assessed during 2 weeks using doubly labeled water) minus resting metabolic rate (measured using indirect calorimetry) in 197 men and women (mean age, 74.8 years) who were free of mobility and cognitive impairments at study baseline (1998-1999). Cognitive function was assessed at baseline and 2 or 5 years later using the Modified Mini-Mental State Examination. Cognitive impairment was defined as a decline of at least 1.0 SD (9 points) between baseline and follow-up evaluations.

RESULTS

After adjustment for baseline Modified Mini-Mental State Examination scores, demographics, fat-free mass, sleep duration, self-reported health, and diabetes mellitus, older adults in the highest sex-specific tertile of AEE had lower odds of incident cognitive impairment than those in the lowest tertile (odds ratio, 0.09; 95% confidence interval, 0.01-0.79). There was also a significant dose response between AEE and incidence of cognitive impairment (P = .05 for trend over tertiles).

CONCLUSIONS

These findings indicate that greater AEE may be protective against cognitive impairment in a dose-response manner. The significance of overall activity in contrast to vigorous or light activity should be determined.

Adipokine ganglioside GM2 activator protein stimulates insulin secretion

Recently, we identified ganglioside GM2 activator protein (GM2AP) as a novel adipokine, and revealed that treatment of cultured cells with GM2AP impairs insulin signal transduction. The aim of this study was to examine the impact of GM2AP on glucose metabolism in vivo. Injection of recombinant GM2AP in mice significantly lowered blood glucose levels in glucose tolerance tests. Administration of GM2AP to mice for 10 days increased serum insulin levels, whereas the contents of glucose, leptin and FFA were significantly decreased. Stimulation of calcium influx and insulin secretion by GM2AP was observed in hamster insulinoma HIT-T15 cells. Blockage of GM2AP function by specific antibodies inhibited GM2AP-induced insulin secretion. These results provide novel insights into the physiological functions of GM2AP in obesity.

Type 2 diabetes and late-onset Alzheimer's disease

BACKGROUND/AIMS

To confirm in a cohort recruited in 1999-2001 our finding in a cohort recruited in 1992-1994 relating type 2 diabetes (T2D) to late-onset Alzheimer's disease (LOAD).

METHODS

Participants were 1,488 persons aged 65 years and older without dementia at baseline from New York City. T2D was ascertained by self-report. Dementia and LOAD were ascertained by standard research procedures. Proportional hazard regression was used for analyses relating T2D and LOAD.

RESULTS

The prevalence of T2D was 17%. There were 161 cases of dementia and 149 cases of LOAD. T2D was related to dementia (hazard ratio = 1.7; 95% confidence interval = 1.4-2.9) and LOAD (1.6; 1.0-2.6) after adjustment for age, sex, education, ethnic group and apolipoprotein E ε4. This association was weaker when only AD - excluding cases of mixed dementia - was considered (hazard ratio = 1.3; 95% confidence interval = 0.8-2.2).

CONCLUSION

T2D is associated with LOAD. Cerebrovascular disease may be an important mediator.

Improved diabetes control in the elderly delays global cognitive decline

OBJECTIVES

To examine whether improved diabetes control is related to better cognitive outcomes.

DESIGN

Randomized control trial.

SETTING

A randomized trial of telemedicine vs. usual care in elderly persons with type 2 diabetes.

PARTICIPANTS

Participants were 2169 persons 55 years and older with type 2 diabetes from New York City and Upstate New York.

INTERVENTION

The diabetes case management intervention was implemented by a diabetes nurse, via a telemedicine unit in the participant's home, and in coordination with the primary care physician.

MEASUREMENTS

Hemoglobin A1c (HbA1c), systolic blood pressure (SBP), and low density lipoprotein cholesterol (LDL), were measured at a baseline visit and at up to 5 annual follow-up visits. Global cognition was measured at those visits with the Comprehensive Assessment and Referral Evaluation (CARE).

RESULT

In mixed models the intervention was related to slower global cognitive decline in the intervention group (p = 0.01). Improvements in HbA1c (p = 0.03), but not SBP or LDL, mediated the effect of the intervention on cognitive decline.

CONCLUSION

Improved diabetes control in the elderly following existing guidelines through a telemedicine intervention was associated with less global cognitive decline. The main mediator of this effect seemed to be improvements in HbA1c.

Adiponectin protects rat hippocampal neurons against excitotoxicity

Adiponectin exerts multiple regulatory functions in the body and in the hypothalamus primarily through activation of its two receptors, adiponectin receptor1 and adiponectin receptor 2. Recent studies have shown that adiponectin receptors are widely expressed in other areas of the brain including the hippocampus. However, the functions of adiponectin in brain regions other than the hypothalamus are not clear. Here, we report that adiponectin can protect cultured hippocampal neurons against kainic acid-induced (KA) cytotoxicity. Adiponectin reduced the level of reactive oxygen species, attenuated apoptotic cell death, and also suppressed activation of caspase-3 induced by KA. Pretreatment of hippocampal primary neurons with an AMPK inhibitor, compound C, abolished adiponectin-induced neuronal protection. The AMPK activator, 5-aminoimidazole-4-carboxamide-1-beta-D-ribofuranoside, attenuated KA-induced caspase-3 activity. These findings suggest that the AMPK pathway is critically involved in adiponectin-induced neuroprotection and may mediate the antioxidative and anti-apoptotic properties of adiponectin.

Effect of pioglitazone on altered expression of Aβ metabolism-associated molecules in the brain of fructose-drinking rats, a rodent model of insulin resistance

Accumulation of β-amyloid (Aβ) peptide in the brain is a major hallmark of Alzheimer's disease. An optimal brain insulin level promotes Aβ clearance, which may play protective roles against Alzheimer's disease. In this study we examined the role of dietary conditions leading to insulin resistance on amyloidosis in fructose-drinking rats. Further investigations tested pioglitazone, an insulin sensitizer, intervention on the altered amyloidosis in this rodent model of insulin resistance. Six-week-old male Wistar rats were fed a standard commercial diet and water without (control) or with 10% fructose for 16 weeks. The animals were randomly divided into 4 groups (n=10): non-treated and water-drinking rats (control group); pioglitazone treated and water-drinking (control treatment group); non-treated and fructose-drinking rats (fructose group) and pioglitazone-treated and fructose-drinking rats (fructose treatment group). Pioglitazone was given at the dose of 10mg/kgd by gavage for the last 12 weeks of the 16-week period. We found that diet-induced insulin resistance induced Aβ overproduction with altered expression of Aβ metabolism-associated molecules, which corresponded with increased β-secretase-1 (BACE1), γ-secretase (PS-1) activities and decreased insulin degrading enzyme (IDE) activities, but not neprilysin in the cortex and hippocampus. Additionally, pioglitazone treatment prevented all these observed abnormalities. This study indicates that insulin resistance induced by fructose-drinking affects the expression of Aβ metabolism-associated molecules that are responsible for Aβ deposition and pioglitazone treatment negatively modulate amyloidogenesis.

Neuroprotective properties of GLP-1: theoretical and practical applications

In the past few years, the development of pharmaceutical agents that enhance the physiological effects of glucagon-like peptide-1 (GLP-1), either through GLP-1 receptor agonism (GLP-1 agonists) or by inhibiting GLP-1 degradation (dipeptidylpeptidase-4 inhibitors) has broadened the range of treatment options for individuals with type 2 diabetes. It has been recognized for some time that GLP-1 also has extra-pancreatic effects, notably targeting the brain, where it regulates appetite and satiety, as well as peripheral functions highly controlled by the autonomic nervous system, such as gastric emptying. Furthermore, data are beginning to emerge that indicate a potential role for GLP-1 in neuroprotection. The increased risk of Alzheimer's disease, Parkinson's disease and stroke in people with type 2 diabetes suggests that shared mechanisms/pathways of cell death, possibly related to insulin dysregulation, may underlie all of these disorders. Although the disease anatomy varies with each disorder, a wide range of genetic and environmental triggers result in activation of similar biochemical pathways in all of them, suggesting a complex network of biochemical events that feed in to a final common path towards cellular dysfunction and death. This article summarizes the evidence for neuronal activity of GLP-1 and examines the limited data that currently exist on the therapeutic potential of GLP-1 in specific neurological and neurodegenerative conditions, namely Alzheimer's disease, Parkinson's disease, Huntingdon's disease, stroke and peripheral sensory neuropathy.

Insulin metabolism and the risk of Alzheimer disease: the Rotterdam Study

OBJECTIVE

Diabetes mellitus has been associated with an increased risk of Alzheimer disease (AD), but how it exerts its effect remains controversial. Possible pathophysiologic mechanisms are glucose toxicity and a direct effect of insulin on amyloid metabolism. Most studies had short follow-up, and longer-term effects of diabetes on AD risk are unknown. We investigated whether fasting glucose and insulin levels and insulin resistance are associated with the risk of AD and whether this risk is constant over time.

METHODS

The study was based on 3,139 participants of the Rotterdam Study, a population-based cohort study. All subjects were free from dementia, did not have a history of diabetes, and had fasting levels of glucose and insulin measured at baseline. Insulin resistance was estimated with the homeostasis model assessment. We investigated how fasting glucose, insulin, and insulin resistance are related to the risk of AD in 3 different strata according to time-to-event, using Cox proportional hazards models.

RESULTS

During follow-up, 211 participants developed AD, 71 of them within 3 years of baseline. Levels of insulin and insulin resistance were associated with a higher risk of AD within 3 years of baseline. After 3 years, the risk was no longer increased. Glucose was not associated with a higher risk of AD. There was no interaction of APOE ε4 carriership and insulin metabolism on the risk of AD.

CONCLUSIONS

Our findings suggest that insulin metabolism influences the clinical manifestation of AD only within 3 years.

Linking cardiometabolic disorders to sporadic Alzheimer's disease: a perspective on potential mechanisms and mediators

There is increasing evidence that the incidence of Alzheimer's disease (AD) is significantly influenced by cardiovascular risk factors in association with a cluster of metabolic diseases including diabetes and atherosclerosis. The shared risk is also reflected in the dietary and lifestyle links to both metabolic disorders and AD-type cognitive dysfunction. Recent studies with genetic and diet-induced animal models have begun to illuminate convergent mechanisms and mediators between these two categories of disease conditions with distinct tissue-specific pathologies. Although it is clear that peripheral inflammation and insulin resistance are central to the pathogenesis of the disorders of metabolic syndrome, it seems that the same mechanisms are also in play across the blood-brain barrier that lead to AD-like molecular and cognitive changes. This review highlights these convergent mechanisms and discusses the role of cerebrovascular dysfunction as a conduit to brain emergence of these pathogenic processes that might also represent future therapeutic targets in AD in common with metabolic disorders.

Presenilin-1 regulates induction of hypoxia inducible factor-1α: altered activation by a mutation associated with familial Alzheimer's disease

Background

Mutations in presenilin-1 (Psen1) cause familial Alzheimer's disease (FAD). Both hypoxia and ischemia have been implicated in the pathological cascade that leads to amyloid deposition in AD. Here we investigated whether Psen1 might regulate hypoxic responses by modulating induction of the transcription factor hypoxia inducible factor 1-α (HIF-1α).

Results

In fibroblasts that lack Psen1 induction of HIF-1α was impaired in response to the hypoxia mimetic cobalt chloride, as well as was induction by insulin and calcium chelation. Reintroduction of human Psen1 using a lentiviral vector partially rescued the responsiveness of Psen1-/- fibroblasts to cobalt chloride induction. HIF-1α induction did not require Psen1's associated γ-secretase activity. In addition, the failure of insulin to induce HIF-1α was not explicable on the basis of failed activation of the phosphatidylinositol 3-kinase (PI3K/Akt) pathway which activated normally in Psen1-/- fibroblasts. Rather we found that basal levels of HIF-1α were lower in Psen1-/- fibroblasts and that the basis for lower constitutive levels of HIF-1α was best explained by accelerated HIF-1α degradation. We further found that Psen1 and HIF-1α physically interact suggesting that Psen1 may protect HIF-1α from degradation through the proteasome. In fibroblasts harboring the M146V Psen1 FAD mutation on a mouse Psen1 null background, metabolic induction of HIF-1α by insulin was impaired but not hypoxic induction by cobalt chloride. Unlike Psen1-/- fibroblasts, basal levels of HIF-1α were normal in FAD mutant fibroblasts but activation of the insulin-receptor pathway was impaired. Interestingly, in Psen1-/- primary neuronal cultures HIF-1α was induced normally in response to cobalt chloride but insulin induction of HIF-1α was impaired even though activation of the PI3K/Akt pathway by insulin proceeded normally in Psen1-/- neuronal cultures. Basal levels of HIF-1α were not significantly different in Psen1-/- neurons and HIF-1α levels were normal in Psen1-/- embryos.

Conclusions

Collectively these studies show that Psen1 regulates induction of HIF-1α although they indicate that cell type specific differences exist in the effect of Psen1 on induction. They also show that the M146V Psen1 FAD mutation impairs metabolic induction of HIF-1α, an observation that may have pathophysiological significance for AD.

Contribution of systemic inflammation to chronic neurodegeneration

Systemic infection or inflammation gives rise to signals that communicate with the brain and leads to changes in metabolism and behaviour collectively known as sickness behaviour. In healthy young individuals, these changes are normally transient with no long-term consequences. The microglia are involved in the immune to brain signalling pathways. In the aged or diseased brain, the microglia have a primed phenotype as a consequence of changes in their local microenvironment. Systemic inflammation impacts on these primed microglia and switches them from a relatively benign to an aggressive phenotype with the enhanced synthesis of pro-inflammatory mediators. Recent evidence suggests that systemic inflammation contributes to the exacerbation of acute symptoms of chronic neurodegenerative disease and may accelerate disease progression. The normal homeostatic role that microglia play in signalling about systemic infections and inflammation becomes maladaptive in the aged and diseased brain and this offers a route to therapeutic intervention. Prompt treatment of systemic inflammation or blockade of signalling pathways from the periphery to the brain may help to slow neurodegeneration and improve the quality of life for individuals suffering from chronic neurodegenerative disease.

Alzheimer's disease: brain expression of a metabolic disorder?

Alzheimer's disease (AD) is the most common form of dementia and is of rapidly increasing health, social and economic impact. Recent evidence suggests a strict link between metabolic disorders and AD. In the last decade much attention has focused specifically on the connection between dysfunction of lipid metabolism and AD. Here we discuss aspects of lipid regulation, including changes in cholesterol levels, function of apolipoproteins and leptin, and how these relate to AD pathogenesis. Despite the vast literature available, many aspects still need clarification. Nevertheless, the route is already delineated to directly connect aspects of lipid regulation to AD. This could represent a starting point to identify novel potential targets for a preventive and/or treatment strategy of the disease.

Design, synthesis, and biological evaluation of a novel class of gamma-secretase modulators with PPARgamma activity

We present a novel class of dual modulators of gamma-secretase and peroxisome proliferator-activated receptor gamma (PPARgamma) based on the structure of 2-(bis(phenethoxy)pyrimidine-2-ylthio)hexanoic acid 8 (IC(50)(Abeta42) = 22.8 microM, EC(50)(PPARgamma) = 8.3 microM). The modulation of both targets with approved drugs (i.e., amyloid-beta 42 (Abeta42)-lowering NSAIDs for gamma-secretase and glitazones for PPARgamma) has demonstrated beneficial effects in in vitro and in vivo models of Alzheimer's disease (AD). However, although NSAIDs and PPARgamma agonists share similar structural features, no druglike compounds with dual activities as gamma-secretase modulators (GSMs) and PPARgamma agonists have been designed so far. On the basis of our initial lead structure 8, we present the structure-activity relationships (SARs) of broad structural variations. A significant improvement was reached by the introduction of p-trifluoromethyl substituents at the phenyl residues yielding compound 16 (IC(50)(Abeta42) = 6.0 microM, EC(50)(PPARgamma) = 11.0 microM) and the replacement of the two phenyl residues of 8 by cyclohexyl yielding compound 22 (IC(50)(Abeta42) = 5.1 microM, EC(50)(PPARgamma) = 6.6 microM).

Physical activity over the life course and its association with cognitive performance and impairment in old age

OBJECTIVE

To determine how physical activity at various ages over the life course is associated with cognitive impairment in late life.

DESIGN

Cross-sectional study.

SETTING

Four U.S. sites.

PARTICIPANTS

Nine thousand three hundred forty-four women aged 65 and older (mean 71.6) who self-reported teenage, age 30, age 50, and late-life physical activity.

MEASUREMENTS

Logistic regression was used to determine the association between physical activity status at each age and likelihood of cognitive impairment (modified Mini-Mental State Examination (mMMSE) score >1.5 standard deviations below the mean, mMMSE score

RESULTS

Women who reported being physically active had a lower prevalence of cognitive impairment in late life than women who were inactive at each time (teenage: 8.5% vs 16.7%, adjusted odds ratio (AOR)=0.65, 95% confidence interval (CI)=0.53-0.80; age 30: 8.9% vs 12.0%, AOR=0.80, 95% CI=0.67-0.96); age 50: 8.5% vs 13.1%, AOR=0.71, 95% CI=0.59-0.85; old age: 8.2% vs 15.9%, AOR=0.74, 95% CI=0.61-0.91). When the four times were analyzed together, teenage physical activity was most strongly associated with lower odds of late-life cognitive impairment (OR=0.73, 95% CI=0.58-0.92). However, women who were physically inactive as teenagers and became active in later life had lower risk than those who remained inactive.

CONCLUSIONS

Women who reported being physically active at any point over the life course, especially as teenagers, had a lower likelihood of cognitive impairment in late life. Interventions should promote physical activity early in life and throughout the life course.

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Key Words

• physical activity
• exercise
• cognition
• cognitive impairment
• life course

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MESH Headings

• Adolescent
• Adult
• Age Factors
• Aged
• Cognition Disorders/epidemiology
• Cross-Sectional Studies
• Exercise/psychology
• Female
• Health Behavior
• Humans
• Life Style
• Logistic Models
• Middle Aged
• Motor Activity
• Prevalence
• United States

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Grants

• R01 AR035583 NIAMS NIH HHS
• AR35582 NIAMS NIH HHS
• R01 AR035584 NIAMS NIH HHS
• AG05394 NIA NIH HHS
• R01 AG027576 NIA NIH HHS
• 2 R01 AG027574-22A1 NIA NIH HHS
• R01 AR035582 NIAMS NIH HHS
• R01 AG005394 NIA NIH HHS
• AR35584 NIAMS NIH HHS
• R01 AG027574 NIA NIH HHS
• 2 R01 AG005394-22A1 NIA NIH HHS
• AG05407 NIA NIH HHS
• K24 AG031155 NIA NIH HHS
• K01 AG024069 NIA NIH HHS
• R01 AG005407 NIA NIH HHS
• R01 AG027576-22 NIA NIH HHS
• AR35583 NIAMS NIH HHS

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Affiliation(s)

Laura E Middleton Heart and Stroke Foundation, Center for Stroke Recovery, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada.
Deborah E Barnes
Li-Yung Lui
Kristine Yaffe

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Collaborators Collapse

Insulin-resistance and metabolic syndrome are related to executive function in women in a large family-based study

While type 2 diabetes is well-known to be associated with poorer cognitive performance, few studies have reported on the association of metabolic syndrome (MetS) and contributing factors, such as insulin-resistance (HOMA-IR), low adiponectin-, and high C-reactive protein (CRP)- levels. We studied whether these factors are related to cognitive function and which of the MetS components are independently associated. The study was embedded in an ongoing family-based cohort study in a Dutch population. All participants underwent physical examinations, biomedical measurements, and neuropsychological testing. Linear regression models were used to determine the association between MetS, HOMA-IR, adiponectin levels, CRP, and cognitive test scores. Cross-sectional analyses were performed in 1,898 subjects (mean age 48 years, 43% men). People with MetS had significantly higher HOMA-IR scores, lower adiponectin levels, and higher CRP levels. MetS and high HOMA-IR were associated with poorer executive function in women (P = 0.03 and P = 0.009). MetS and HOMA-IR are associated with poorer executive function in women.

The link between iron, metabolic syndrome, and Alzheimer's disease

Both Alzheimer's disease (AD), the most common form of dementia, and type-2 diabetes mellitus (T2DM), a disease associated with metabolic syndrome (MetS), affect a great number of the world population and both have increased prevalence with age. Recently, many studies demonstrated that pre-diabetes, MetS, and T2DM are risk factors in the development of AD and have many common mechanisms. The main focus of studies is the insulin resistance outcome found both in MetS as well as in brains of AD subjects. However, oxidative stress (OS)-related mechanisms, which are well known to be involved in AD, including mitochondrial dysfunction, elevated iron concentration, reactive oxygen species (ROS), and stress-related enzyme or proteins (e.g. heme oxygenase-1, transferrin, etc.), have not been elucidated in MetS or T2DM brains although OS and iron are involved in the degeneration of the pancreatic islet β cells. Therefore, this review sets to cover the current literature regarding OS and iron in MetS and T2DM and the similarities to mechanisms in AD both in human subjects as well as in animal models.

Microglia in neurodegenerative disease

Microglia, the resident macrophages of the CNS, are exquisitely sensitive to brain injury and disease, altering their morphology and phenotype to adopt a so-called activated state in response to pathophysiological brain insults. Morphologically activated microglia, like other tissue macrophages, exist as many different phenotypes, depending on the nature of the tissue injury. Microglial responsiveness to injury suggests that these cells have the potential to act as diagnostic markers of disease onset or progression, and could contribute to the outcome of neurodegenerative diseases. The persistence of activated microglia long after acute injury and in chronic disease suggests that these cells have an innate immune memory of tissue injury and degeneration. Microglial phenotype is also modified by systemic infection or inflammation. Evidence from some preclinical models shows that systemic manipulations can ameliorate disease progression, although data from other models indicates that systemic inflammation exacerbates disease progression. Systemic inflammation is associated with a decline in function in patients with chronic neurodegenerative disease, both acutely and in the long term. The fact that diseases with a chronic systemic inflammatory component are risk factors for Alzheimer disease implies that crosstalk occurs between systemic inflammation and microglia in the CNS.

Promising strategies for the prevention of dementia

The incidence and prevalence of dementia are expected to increase several-fold in the coming decades. Given that the current pharmaceutical treatment of dementia can only modestly improve symptoms, risk factor modification remains the cornerstone for dementia prevention. Some of the most promising strategies for the prevention of dementia include vascular risk factor control, cognitive activity, physical activity, social engagement, diet, and recognition of depression. In observational studies, vascular risk factors-including diabetes, hypertension, dyslipidemia, and obesity-are fairly consistently associated with increased risk of dementia. In addition, people with depression are at high risk for cognitive impairment. Population studies have reported that intake of antioxidants or polyunsaturated fatty acids may be associated with a reduced incidence of dementia, and it has been reported that people who are cognitively, socially, and physically active have a reduced risk of cognitive impairment. However, results from randomized trials of risk factor modification have been mixed. Most promising, interventions of cognitive and physical activity improve cognitive performance and slow cognitive decline. Future studies should continue to examine the implication of risk factor modification in controlled trials, with particular focus on whether several simultaneous interventions may have additive or multiplicative effects.

Substrate competitive GSK-3 inhibitors - strategy and implications

Glycogen synthase kinase-3 (GSK-3) is a highly conserved protein serine/threonine kinase ubiquitously distributed in eukaryotes as a constitutively active enzyme. Abnormally high GSK-3 activity has been implicated in several pathological disorders, including diabetes and neuron degenerative and affective disorders. This led to the hypothesis that inhibition of GSK-3 may have therapeutic benefit. Most GSK-3 inhibitors developed so far compete with ATP and often show limited specificity. Our goal is to develop inhibitors that compete with GSK-3 substrates, as this type of inhibitor is more specific and may be useful for clinical applications. We have employed computational, biochemical, and molecular analyses to gain in-depth understanding of GSK-3's substrate recognition. Here we argue that GSK-3 is a promising drug discovery target and describe the strategy and practice for developing specific substrate-competitive inhibitors of GSK-3.

Carotid artery ultrasound and echocardiography testing to lower the prevalence of Alzheimer's disease

The use of two clinic office techniques, carotid artery ultrasound and echocardiography (CAUSE), to detect deficient brain blood flow delivery in the healthy, cognitively normal, older individual is proposed. Evidence indicates that persistent heart-to-brain blood flow deficit involving low cardiac output or low ejection fraction and carotid artery narrowing can promote cognitive impairment and that such impairment may lead to Alzheimer's disease (AD) or vascular dementia (VaD). A number of independent epidemiologic studies reported cardiovascular and cerebrovascular disease to be risk factors to AD and VaD. The clinical rationale for CAUSE is to detect and prevent progression of cognitive dysfunction in elderly persons and is based on the general understanding that mild cognitive impairment is a preclinical threshold to AD or VaD with high conversion rates to either dementia. The use of CAUSE is anticipated to prevent or attenuate, by appropriate clinical management, mild cognitive impairment arising from persistent brain hypoperfusion, a condition implicated in the promotion of cognitive impairment in the elderly and a common preclinical feature seen in AD and VaD. As detection of lowered cerebral perfusion from cardiac and carotid artery pathology is achieved using these cost-effective, noninvasive, and relatively accurate ultrasound procedures, a significant reduction in the number of new AD and VaD cases would be anticipated after appropriate patient treatment. In this context, a brief summary is presented outlining recent medical and surgical treatments that may improve cerebral blood flow insufficiency. The merit of CAUSE in screening and treating mentally healthy elderly persons who are identified as being at risk of cognitive decline is that it could blunt the soaring socioeconomic impact that will hammer the health care system of many nations by the mounting dementia prevalence rate expected in the next 25 years. A 5- year delay in the onset of AD could reduce the prevalence of AD by 50%. We are making preparations to test the merit of CAUSE in a clinical study of a cognitively healthy elderly population.

Systemic inflammation and disease progression in Alzheimer disease

BACKGROUND

Acute and chronic systemic inflammation are characterized by the systemic production of the proinflammatory cytokine tumor necrosis factor alpha (TNF-alpha) that plays a role in immune to brain communication. Previous preclinical research shows that acute systemic inflammation contributes to an exacerbation of neurodegeneration by activation of primed microglial cells.

OBJECTIVE

To determine whether acute episodes of systemic inflammation associated with increased TNF-alpha would be associated with long-term cognitive decline in a prospective cohort study of subjects with Alzheimer disease.

METHODS

Three hundred community-dwelling subjects with mild to severe Alzheimer disease were cognitively assessed, and a blood sample was taken for systemic inflammatory markers. Each subject's main caregiver was interviewed to assess the presence of incident systemic inflammatory events. Assessments of both patient and caregiver were repeated at 2, 4, and 6 months.

RESULTS

Acute systemic inflammatory events, found in around half of all subjects, were associated with an increase in the serum levels of proinflammatory cytokine TNF-alpha and a 2-fold increase in the rate of cognitive decline over a 6-month period. High baseline levels of TNF-alpha were associated with a 4-fold increase in the rate of cognitive decline. Subjects who had low levels of serum TNF-alpha throughout the study showed no cognitive decline over the 6-month period.

CONCLUSIONS

Both acute and chronic systemic inflammation, associated with increases in serum tumor necrosis factor alpha, is associated with an increase in cognitive decline in Alzheimer disease.

Getting the iron out: phlebotomy for Alzheimer's disease?

This communication explores the temporal link between the age-associated increase in body iron stores and the age-related incidence of Alzheimer's disease (AD), the most prevalent cause of senile dementia. Body iron stores that increase with age could be pivotal to AD pathogenesis and progression. Increased stored iron is associated with common medical conditions such as diabetes and vascular disease that increase risk for development of AD. Increased stored iron could also promote oxidative stress/free radical damage in vulnerable neurons, a critical early change in AD. A ferrocentric model of AD described here forms the basis of a rational, easily testable experimental therapeutic approach for AD, which if successful, would be both widely applicable and inexpensive. Clinical studies have shown that calibrated phlebotomy is an effective way to reduce stored iron safely and predictably without causing anemia. We hypothesize that reducing stored iron by calibrated phlebotomy to avoid iron deficiency will improve cerebrovascular function, slow neurodegenerative change, and improve cognitive and behavioral functions in AD. The hypothesis is eminently testable as iron reduction therapy is useful for chronic diseases associated with iron excess such as nonalcoholic steatohepatitis (NASH), atherosclerosis, hereditary hemochromatosis and thalassemia. Testing this hypothesis could provide valuable insight into the causation of AD and suggest novel preventive and treatment strategies.

Obesity: What is an elderly population growing into?

OBJECTIVES

Obesity is currently a major public health concern; however, there is little data available on the prevalence and impact of obesity within the elderly population. This review examines the prevalence and health effects of obesity among individuals aged > or =50.

METHODS

PubMed (1996-2008) and PsychInfo (2002-2008) search engines were used to retrieve qualified peer-reviewed articles focusing on obesity or a health condition correlated with obesity using BMI or other weight index as a defining variable; and studies limited to the elderly (age 60+) or pre-elderly (50+).

RESULTS

Worldwide, the elderly population is increasingly becoming obese regardless of socio-economic status. Among elderly persons, obesity increases the risks for a variety of morbidity conditions including cancers, diabetes, hypertension, stroke, heart disease, metabolic syndrome, obstructive sleep apnea syndrome, osteoarthritis, depression, disability, and lower scores on quality of life measures. In some reports, obesity has been linked to Alzheimer's disease and other forms of cognitive decline. Obesity significantly increases healthcare costs and nursing homes are currently ill equipped to address the needs of the rising number of obese residents.

CONCLUSIONS

Obesity is increasing in the elderly population worldwide and is expected to continue to rise. Obesity is associated with disease and disability in addition to escalating healthcare costs, and hospitals and nursing homes are ill equipped to serve the obese elderly. It is imperative that research efforts and funding be devoted to studying the effects and the reduction of obesity in the elderly population.

The role of metabolic disorders in Alzheimer disease and vascular dementia: two roads converged

In recent years a rapidly increasing number of studies has focused on the relationship between dementia and metabolic disorders such as diabetes, obesity, hypertension, and dyslipidemia. Etiological heterogeneity and comorbidity pose challenges for determining relationships among metabolic disorders. The independent and interactive effects of brain vascular injury and classic pathological agents such as beta-amyloid have also proved difficult to distinguish in human patients, blurring the lines between Alzheimer disease and vascular dementia. This review highlights recent work aimed at identifying convergent mechanisms such as insulin resistance that may underlie comorbid metabolic disorders and thereby increase dementia risk. Identification of such convergent factors will not only provide important insight into the causes and interdependencies of late-life dementias but will also inspire novel strategies for treating and preventing these disorders.