Dissociating effects of aging and genetic risk of sporadic Alzheimer's disease on path integration

A cognitive-motor framework for spatial navigation in aging and early-stage Alzheimer's disease

Spatial navigation is essential for wellbeing and independence and shows significant declines as part of age-related neurodegenerative disorders, such as Alzheimer's disease. Navigation is also one of the earliest behaviors impacted by this devastating disease. Neurobiological models of aging and spatial navigation have focused primarily on the cognitive factors that account for impaired navigation abilities during the course of healthy aging and early stages of preclinical and prodromal Alzheimer's disease. The contributions of physical factors that are essential to planning and executing movements during successful navigation, such as gait and dynamic balance, are often overlooked despite also being vulnerable to early stages of neurodegenerative disease. We review emerging evidence that spatial navigation and functional mobility each draw on highly overlapping sensory systems, cognitive processes, and brain structures that are susceptible to healthy and pathological aging processes. Based on this evidence, we provide an alternative to models that have focused primarily on spatial navigation as a higher order cognitive function dependent on brain areas such as the hippocampus and entorhinal cortex. Instead, we argue that spatial navigation may offer an ecologically valid cognitive-motor phenotype of age-related cognitive dysfunction. We propose that dual cognitive-motor deficits in spatial navigation may arise from early changes in neuromodulatory and peripheral sensory systems that precede changes in regions such as the entorhinal cortex.

Virtual Reality and Serious Videogame-Based Instruments for Assessing Spatial Navigation in Alzheimer's Disease: A Systematic Review of Psychometric Properties

Over the past decade, research using virtual reality and serious game-based instruments for assessing spatial navigation and spatial memory in at-risk and AD populations has risen. We systematically reviewed the literature since 2012 to identify and evaluate the methodological quality and risk of bias in the analyses of the psychometric properties of VRSG-based instruments. The search was conducted primarily in July-December 2022 and updated in November 2023 in eight major databases. The quality of instrument development and study design were analyzed in all studies. Measurement properties were defined and analyzed according to COSMIN guidelines. A total of 1078 unique records were screened, and following selection criteria, thirty-seven studies were analyzed. From these studies, 30 instruments were identified. Construct and criterion validity were the most reported measurement properties, while structural validity and internal consistency evidence were the least reported. Nineteen studies were deemed very good in construct validity, whereas 11 studies reporting diagnostic accuracy were deemed very good in quality. Limitations regarding theoretical framework and research design requirements were found in most of the studies. VRSG-based instruments are valuable additions to the current diagnostic toolkit for AD. Further research is required to establish the psychometric performance and clinical utility of VRSG-based instruments, particularly the instrument development, content validity, and diagnostic accuracy for preclinical AD screening scenarios. This review provides a straightforward synthesis of the state of the art of VRSG-based instruments and suggests future directions for research.

Path integration impairments reveal early cognitive changes in Subjective Cognitive Decline

Path integration, the ability to track one's position using self-motion cues, is critically dependent on the grid cell network in the entorhinal cortex, a region vulnerable to early Alzheimer's disease pathology. In this study, we examined path integration performance in individuals with subjective cognitive decline (SCD), a group at increased risk for Alzheimer's disease, and healthy controls using an immersive virtual reality task. We developed a Bayesian computational model to decompose path integration errors into distinct components. SCD participants exhibited significantly higher path integration error, primarily driven by increased memory leak, while other modelling-derived error sources, such as velocity gain, sensory and reporting noise, remained comparable across groups. Our findings suggest that path integration deficits, specifically memory leak, may serve as an early marker of neurodegeneration in SCD and highlight the potential of self-motion-based navigation tasks for detecting pre-symptomatic Alzheimer's disease-related cognitive changes.

Teaser

Virtual reality, computational modelling, and biomarkers uncover path integration deficits, distinguishing pre-symptomatic Alzheimer's from normal aging.

Rotation errors in path integration are associated with Alzheimer's disease tau pathology: a cross-sectional study

BACKGROUND

Early Alzheimer's disease diagnosis is crucial for preventive therapy development. Standard neuropsychological evaluation does not identify clinically normal individuals with brain amyloidosis, the first stage of the pathology, defined as preclinical Alzheimer's disease. Spatial navigation assessment, in particular path integration, appears promising to detect preclinical symptoms, as the medial temporal lobe plays a key role in navigation and is the first cortical region affected by tau pathology.

METHODS

We have conducted a cross-sectional study. We related the path integration performance of 102 individuals without dementia, aged over 50, to amyloid and tau pathologies, measured using positron emission tomography. We included 75 clinically normal individuals (19 with brain amyloidosis, 56 without) and 27 individuals with mild cognitive impairment (18 with brain amyloidosis, 9 without). We fitted linear mixed models to predict the path integration performances according to amyloid status or tau pathology in the medial temporal lobal, adjusting for age, gender, cognitive status, education, and video game experience. We decomposed the error into rotation and distance errors.

RESULTS

We observed that clinically normal adults with brain amyloidosis (preclinical Alzheimer's disease) had spatial navigation deficits when relying only on self-motion cues. However, they were able to use a landmark to reduce their errors. Individuals with mild cognitive impairment had deficits in path integration that did not improve when a landmark was added in the environment. The amyloid status did not influence performance among individuals with mild cognitive impairment. Among all individuals, rotation, but not distance, errors increased with the level of tau pathology in the medial temporal lobe.

CONCLUSION

Our results suggest that path integration performance in an environment without external cues allows identifying individuals with preclinical Alzheimer's disease, before overt episodic memory impairment is noticeable. Specifically, we demonstrated that poor angular estimation is an early cognitive marker of tau pathology, whereas distance estimation relates to older ages, not to Alzheimer's disease.

TRIAL REGISTRATION

Eudra-CT 2018-003473-94.

Tau PET Imaging With [18F]MK-6240: Limited Affinity for Primary Tauopathies and High Specificity for Alzheimer's Disease

INTRODUCTION

Second-generation tau-PET tracers like [18F]MK-6240 are increasingly used both for diagnosing and quantifying Alzheimer's Disease (AD) tauopathy. However, while [18F]MK-6240 tau-PET has demonstrated excellent sensitivity for AD tauopathy, data assessing its specificity and binding in non-AD tauopathies are still scarce.

METHODS

Participants were assigned to exclusive categorical diagnoses based on their amyloid (Aβ) and cognitive status. We quantified mesiotemporal (MTL) and neocortical [18F]MK-6240 tau-PET signal in 28 Aβ- cognitively impaired (CI) patients presenting various non-AD neurodegenerative disorders. Tau-PET quantifications were compared with Aβ- cognitively unimpaired (CU) subjects (n = 51) and Aβ+ CI patients (n = 77).

RESULTS

Among the 28 Aβ- impaired subjects, only five presented significant and isolated mesiotemporal signal, most of them being suspected of primary age-related tauopathy (PART). Only two Aβ- impaired patients (7%) presented positive neocortical signal, both being diagnosed with fronto-temporal degeneration (FTD). The Tau-PET results of all the remaining Aβ- patients were comparable to the CU population, including eight other FTD patients. Importantly, 4R-only tauopathies (CBD and PSP) and sv-PPA were negative.

CONCLUSION

[18F]MK-6240 tau-PET has a special affinity for tauopathies involving 3R/4R paired helical filaments: AD, PART (Aβ- subjects with MTL-restricted tau-PET signal) and some forms of FTD while most primary tauopathies do not exhibit significant cortical signal. Positive neocortical scans are therefore highly specific for AD tauopathy. Based on those and previous results, we propose a diagnostic flowchart for MCI subjects suspected of AD or another tauopathy which may significantly reduce the need for amyloid PET or CSF measurement.

No effect of apolipoprotein E polymorphism on MRI brain activity during movie watching

Apolipoprotein E ε4 is a major genetic risk factor for Alzheimer's disease, and some apolipoprotein E ε4 carriers show Alzheimer's disease-related neuropathology many years before cognitive changes are apparent. Therefore, studying healthy apolipoprotein E genotyped individuals offers an opportunity to investigate the earliest changes in brain measures that may signal the presence of disease-related processes. For example, subtle changes in functional magnetic resonance imaging functional connectivity, particularly within the default mode network, have been described when comparing healthy ε4 carriers to ε3 carriers. Similarly, very mild impairments of episodic memory have also been documented in healthy apolipoprotein E ε4 carriers. Here, we use a naturalistic activity (movie watching), and a marker of episodic memory encoding (transient changes in functional magnetic resonance imaging activity and functional connectivity around so-called 'event boundaries'), to investigate potential phenotype differences associated with the apolipoprotein E ε4 genotype in a large sample of healthy adults. Using Bayes factor analyses, we found strong evidence against existence of differences associated with apolipoprotein E allelic status. Similarly, we did not find apolipoprotein E-associated differences when we ran exploratory analyses examining: functional system segregation across the whole brain, and connectivity within the default mode network. We conclude that apolipoprotein E genotype has little or no effect on how ongoing experiences are processed in healthy adults. The mild phenotype differences observed in some studies may reflect early effects of Alzheimer's disease-related pathology in apolipoprotein E ε4 carriers.

Age differences in spatial memory are mitigated during naturalistic navigation

Spatial navigation deficits are often observed among older adults on tasks that require navigating virtual reality (VR) environments on a computer screen. We investigated whether these age differences are attenuated when tested in more naturalistic and ambulatory virtual environments. In Experiment 1, young and older adults navigated a variant of the Morris Water Maze task in each of two VR conditions: a desktop VR condition which required using a mouse and keyboard to navigate, and an ambulatory VR condition which permitted unrestricted locomotion. In Experiment 2, we examined whether age- and VR-related differences in spatial performance were affected by the inclusion of additional spatial cues. In both experiments, older adults navigated to target locations less precisely than younger individuals in the desktop condition. Age differences were significantly attenuated, however, when tested in the ambulatory VR environment. These findings underscore the importance of developing naturalistic assessments of spatial memory and navigation.

Path integration deficits are associated with phosphorylated tau accumulation in the entorhinal cortex

Alzheimer's disease is a devastating disease that is accompanied by dementia, and its incidence increases with age. However, no interventions have exhibited clear therapeutic effects. We aimed to develop and characterize behavioural tasks that allow the earlier identification of signs preceding dementia that would facilitate the development of preventative and therapeutic interventions for Alzheimer's disease. To this end, we developed a 3D virtual reality task sensitive to the activity of grid cells in the entorhinal cortex, which is the region that first exhibits neurofibrillary tangles in Alzheimer's disease. We investigated path integration (assessed by error distance) in a spatial navigation task sensitive to grid cells in the entorhinal cortex in 177 volunteers, aged 20-89 years, who did not have self-reported dementia. While place memory was intact even in old age, path integration deteriorated with increasing age. To investigate the relationship between neurofibrillary tangles in the entorhinal cortex and path integration deficit, we examined a mouse model of tauopathy (P301S mutant tau-overexpressing mice; PS19 mice). At 6 months of age, PS19 mice showed a significant accumulation of phosphorylated tau only in the entorhinal cortex, associated with impaired path integration without impairments in spatial cognition. These data are consistent with the idea that path integration deficit is caused by the accumulation of phosphorylated tau in the entorhinal cortex. This method may allow the early identification of individuals likely to develop Alzheimer's disease.

Exploring the Remediation of Behavioral Disturbances of Spatial Cognition in Community-Dwelling Senior Citizens with Mild Cognitive Impairment via Innovative Technological Apparatus (BDSC-MCI Project): Protocol for a Prospective, Multi-Center Observational Study

Spatial navigation (SN) has been reported to be one of the first cognitive domains to be affected in Alzheimer's disease (AD), which occurs as a result of progressive neuropathology involving specific brain areas. Moreover, the epsilon 4 isoform of apolipoprotein-E (APOE-ε4) has been associated with both sporadic and familial late-onset AD, and patients with mild cognitive impairment (MCI) due to AD are more likely to progressively deteriorate. Spatial navigation performance will be examined on a sample of 76 community-dwelling senior citizens (25 healthy controls; 25 individuals with subjective cognitive decline (SCD); and 26 patients with MCI due to AD) via a virtual computer-based task (i.e., the AppleGame) and a naturalistic task (i.e., the Detour Navigation Test-modified version) for which a wearable device with sensors will be used for recording gait data and revealing physiological parameters that may be associated with spatial disorientation. We expect that patients with MCI due to AD and APOE-ε4 carriers will show altered SN performances compared to individuals with SCD and healthy controls in the experimental tasks, and that VR testing may predict ecological performance. Impaired SN performances in people at increased risk of developing AD may inform future cognitive rehabilitation protocols for counteracting spatial disorientation that may occur during elders' traveling to unfamiliar locations. The research protocol has been approved by the Ethics Committee of the Istituto Auxologico Italiano. Findings will be published in peer-reviewed medical journals and discussed in national and international congresses.