The earliest cognitive change in a person with familial Alzheimer's disease: presymptomatic neuropsychological features in a pedigree with familial Alzheimer's disease confirmed at necropsy

[1,2,4]Triazolo[1,5-a]pyrimidine Phosphodiesterase 2A Inhibitors: Structure and Free-Energy Perturbation-Guided Exploration

We describe the hit-to-lead exploration of a [1,2,4]triazolo[1,5-a]pyrimidine phosphodiesterase 2A (PDE2A) inhibitor arising from high-throughput screening. X-ray crystallography enabled structure-guided design, leading to the identification of preferred substructural components. Further rounds of optimization used relative binding free-energy calculations to prioritize different substituents from the large accessible chemical space. The free-energy perturbation (FEP) calculations were performed for 265 putative PDE2A inhibitors, and 100 compounds were synthesized representing a relatively large prospective application providing unexpectedly active molecules with IC₅₀'s from 2340 to 0.89 nM. Lead compound 46 originating from the FEP calculations showed PDE2A inhibition IC₅₀ of 1.3 ± 0.39 nM, ∼100-fold selectivity versus other PDE enzymes, clean cytochrome P450 profile, in vivo target occupancy, and promise for further lead optimization.

Predicting Cognitive Decline across Four Decades in Mutation Carriers and Non-carriers in Autosomal-Dominant Alzheimer's Disease

OBJECTIVES

The aim of this study was to investigate cognitive performance including preclinical and clinical disease course in carriers and non-carriers of autosomal-dominant Alzheimer's disease (adAD) in relation to multiple predictors, that is, linear and non-linear estimates of years to expected clinical onset of disease, years of education and age.

METHODS

Participants from five families with early-onset autosomal-dominant mutations (Swedish and Arctic APP, PSEN1 M146V, H163Y, and I143T) included 35 carriers (28 without dementia and 7 with) and 44 non-carriers. All participants underwent a comprehensive clinical evaluation, including neuropsychological assessment at the Memory Clinic, Karolinska University Hospital at Huddinge, Stockholm, Sweden. The time span of disease course covered four decades of the preclinical and clinical stages of dementia. Neuropsychological tests were used to assess premorbid and current global cognition, verbal and visuospatial functions, short-term and episodic memory, attention, and executive function.

RESULTS

In carriers, the time-related curvilinear trajectory of cognitive function across disease stages was best fitted to a formulae with three predictors: years to expected clinical onset (linear and curvilinear components), and years of education. In non-carriers, the change was minimal and best predicted by two predictors: education and age. The trajectories for carriers and non-carriers began to diverge approximately 10 years before the expected clinical onset in episodic memory, executive function, and visuospatial function.

CONCLUSIONS

The curvilinear trajectory of cognitive functions across disease stages was mimicked by three predictors in carriers. In episodic memory, executive and visuospatial functions, the point of diverging trajectories occurred approximately 10 years ahead of the clinical onset compared to non-carriers. (JINS, 2017, 23, 195-203).

Alzheimer's Disease: Prototype of Cognitive Deterioration, Valuable Lessons to Understand Human Cognition

It is important for neurologists to become more familiar with neuropsychological evaluation for Alzheimer disease. The growth of this method in research, as an available, inexpensive, and noninvasive diagnostic approach, which can be administered even by non-specialist-trained examiners, makes this knowledge more necessary than ever. Such knowledge has a basic role in planning national programs in primary health care systems for prevention and early detection of Alzheimer disease. This is more crucial in developing countries, which have higher rates of dementia prevalence along with cardiovascular risk factors, lack of public knowledge about dementia, and limited social support. In addition compared to the neurological hard signs which are tangible and measurable, the concept of cognition seems to be more difficult for the neurologists to evaluate and for the students to understand. Dementia in general and Alzheimer's disease as the prototype of cognitive disorders specifically, play an important role to explore all domains of human cognition through its symptomatology and neuropsychological deficits.

Prospective randomized trial to assess effects of continuing hormone therapy on cerebral function in postmenopausal women at risk for dementia

The objective of this study was to examine the effects of estrogen-based hormone therapy (HT) on regional cerebral metabolism in postmenopausal women (mean age = 58, SD = 5) at risk for development of dementia. The prospective clinical trial design included pre- and post-intervention neuroimaging of women randomized to continue (HT+) or discontinue (HT−) therapy following an average of 10 years of use. The primary outcome measure was change in brain metabolism during the subsequent two years, as assessed with fluorodeoxyglucose-18 positron emission tomography (FDG-PET). Longitudinal FDG-PET data were available for 45 study completers. Results showed that women randomized to continue HT experienced relative preservation of frontal and parietal cortical metabolism, compared with women randomized to discontinue HT. Women who discontinued 17-β estradiol (17βE)-based HT, as well as women who continued conjugated equine estrogen (CEE)-based HT, exhibited significant decline in metabolism of the precuneus/posterior cingulate cortical (PCC) area. Significant decline in PCC metabolism was additionally seen in women taking concurrent progestins (with either 17βE or CEE). Together, these findings suggest that among postmenopausal subjects at risk for developing dementia, regional cerebral cortical metabolism is relatively preserved for at least two years in women randomized to continue HT, compared with women randomized to discontinue HT. In addition, continuing unopposed 17βE therapy is associated specifically with preservation of metabolism in PCC, known to undergo the most significant decline in the earliest stages of Alzheimer's disease.

Trial Registration

ClinicalTrials.govNCT00097058

Ushering in the study and treatment of preclinical Alzheimer disease

Researchers have begun to characterize the subtle biological and cognitive processes that precede the clinical onset of Alzheimer disease (AD), and to set the stage for accelerated evaluation of experimental treatments to delay the onset, reduce the risk of, or completely prevent clinical decline. In this Review, we provide an overview of the experimental strategies, and brain imaging and cerebrospinal fluid biomarker measures that are used in early detection and tracking of AD, highlighting at-risk individuals who could be suitable for preclinical monitoring. We discuss how advances in the field have contributed to reconceptualization of AD as a sequence of biological changes that occur during progression from preclinical AD, to mild cognitive impairment and finally dementia, and we review recently proposed research criteria for preclinical AD. Advances in the study of preclinical AD have driven the recognition that efficacy of at least some AD therapies may depend on initiation of treatment before clinical manifestation of disease, leading to a new era of AD prevention research.

Changes in cognition

The clinical hallmark of Alzheimer's disease (AD) is a gradual decline in cognitive function. For the majority of patients the initial symptom is an impairment in episodic memory, i.e., the ability to learn and retain new information. This is followed by impairments in other cognitive domains (e.g., executive function, language, spatial ability). This impairment in episodic memory is evident among individuals with mild cognitive impairment (MCI) and can be used to predict likelihood of progression to dementia, particularly in association with AD biomarkers. Additionally, cognitively normal individuals who are likely to progress to mild impairment tend to perform more poorly on tests of episodic memory than do those who remain stable. This cognitive presentation is consistent with the pathology of AD, showing neuronal loss in medial temporal lobe structures essential for normal memory. Similarly, there are correlations between magnetic resonance imaging (MRI) measures of medial temporal lobe structures and memory performance among individuals with mild cognitive impairment. There are recent reports that amyloid accumulation may also be associated with memory performance in cognitively normal individuals.

Language performance in Alzheimer's disease and mild cognitive impairment: a comparative review

Mild cognitive impairment (MCI) manifests as memory impairment in the absence of dementia and progresses to Alzheimer's disease (AD) at a rate of around 15% per annum, versus 1-2% in the general population. It thus constitutes a primary target for investigation of early markers of AD. Language deficits occur early in AD, and performance on verbal tasks is an important diagnostic criterion for both AD and MCI. We review language performance in MCI, compare these findings to those seen in AD, and identify the primary issues in understanding language performance in MCI and selecting tasks with diagnostic and prognostic value.

Neuropsychological correlates of whole brain atrophy in Alzheimer's disease

Alzheimer's disease (AD) is associated with excess whole brain volume loss, and progressive cognitive impairment. We aimed to study the extent to which these two potential biomarkers of AD progression are correlated. Forty-six patients with sporadic AD were tested with a neuropsychometric battery including test of verbal and visual memory, vocabulary, arithmetic, naming, visuoperceptual skills and reasoning at two time-points, approximately 1 year apart; annualised rates of change for each test were calculated. Each subject also attended for up to twelve T1-weighted volumetric MRI scans at fixed intervals over a 2-year period. For each individual all possible scan-pairs were positionally registered, and whole brain atrophy rates were calculated using the brain boundary shift integral. Linear mixed models were used to investigate associations between atrophy rate and coincident change in each neuropsychometric score. Each model estimated the effect of a unit change in score, plus the additional effect of a fall to floor, after adjusting for baseline levels. 467 MRI scans were performed, permitting 2199 individual measures of change to be made. The model-derived mean atrophy rate was 2.23% per year with a between-subject SD of 0.99% per year. Increasing atrophy rate was significantly associated with rate of change in a number of non-memory based neuropsychological scores, with the strongest association seen with longitudinal change in matrix reasoning (p=0.004). These results provide further evidence that cerebral atrophy is a clinically relevant marker of AD progression. This methodology whereby data from patients falling to floor on a given test may be included and accounted for, rather than discarded, may find broader application in clinical studies incorporating neuropsychometric outcomes.

Cognitive changes in the preclinical phase of familial Alzheimer's disease

Few studies have examined the presence of linguistic deficits in the preclinical phase of Alzheimer's disease (AD). A total of 19 healthy carriers of the E280A presenilin-1 gene mutation in chromosome 14 and 21 noncarrier family members from Antioquia, Colombia, were administered a neurolinguistic evaluation of lexical-semantic processes. Both groups were similar in age, educational level, and gender. Carriers scored significantly lower than noncarriers on naming of famous faces. Cognitive changes in lexical-semantic tasks can be detected before the clinical diagnosis of probable familial AD, and a neurolinguistic evaluation may be a useful tool in the early clinical diagnosis of sporadic AD as well.

Hippocampal atrophy in the healthy is initially linear and independent of age

Patients with minimal cognitive impairment (MCI) or Alzheimer's disease (AD) have smaller hippocampal volumes (HV) and increased rates of HV loss (rHVL). A 6-year study was conducted to assess rHVL in healthy aging subjects (HC) in which four MRI scans, each 2 years apart, were obtained on 26 HC with a mean age of 58.8 years when entering the study. rHVLs were linear and significantly differed among subjects, even those sharing an identical apoliporotein E genotype, ranging from .027 to .191 cc/year (S.D. = .022 cc/year), and were not affected by age or sex. rHVL, but not HV, at time of subject entry, was found to predict performance on the delayed recall measure of the Selective Reminder Task obtained 6 years after subject entry into study. Although the molecular events underlying rHVL are unclear, the significance of rHVL in subjects in their sixth and seventh decades of life for predicting age-related cognitive trajectories and whether changes in rHVLs foreshadow the development of MCI are the subject of ongoing study.

Correlations between the Functional-Cognitive Assessment Scale and the Alzheimer's Disease Assessment Scale when administered to patients with dementia residing in long-term care

The Alzheimer Disease Assessment Scale (ADAS) and the Functional Cognitive Assessment Scale (FUCAS) examine the cognitive performance of patients with dementia. ADAS has been widely used as a clinical instrument, mainly in clinical trials. FUCAS is a useful tool in diagnosing early dementia since it examines executive skills. Moreover, it is sensitive to the subtle changes that occur during the progress of the disease. The aim of this study was to examine the possible correlations between FUCAS and ADAS. The 2 neuropsychological scales were administered to 32 patients with dementia residing in long-term care. They were 12 men and 20 women, 65 to 90 years old, with 4 to 12 years of education. Twenty-four patients were reassessed 3 months after the first assessment, with the same scales. Pearson's correlation showed that the total score of FUCAS correlated significantly with the total score of ADAS: r = 0.80 (P < .01). The t test showed that changes over the 3 months for FUCAS were more significant than ADAS, suggesting that FUCAS is a more sensitive tool.

Is aging part of Alzheimer's disease, or is Alzheimer's disease part of aging?

For 70 years after Alois Alzheimer described a disorder of tangle-and-plaque dementia, Alzheimer's disease was a condition of the relatively young. Definitions of Alzheimer's disease (AD) have, however, changed over the past 30 years and under the revised view AD has truly become an age-related disease. Most now diagnosed with AD are elderly and would not have been diagnosed with AD as originally conceived. Accordingly, younger patients that qualify for a diagnosis of AD under both original and current Alzheimer's disease constructs now represent an exceptionally small percentage of the diagnosed population. The question of whether pathogenesis of the "early" and "late" onset cases is similar enough to qualify as a single disease was previously raised although not conclusively settled. Interestingly, debate on this issue has not kept pace with advancing knowledge about the molecular, biochemical and clinical underpinnings of tangle-and-plaque dementias. Since the question of whether both forms of AD share a common pathogenesis could profoundly impact diagnostic and treatment development efforts, it seems worthwhile to revisit this debate.

How should we measure nutrition-induced improvements in memory?

There is a basic distinction between declarative memories, which can be stated verbally, and non-declarative memory, such as how to ride a bicycle, which cannot be expressed in words. With age it is the performance of declarative memory, particularly episodic memory that requires recall of events placed in time, that declines. As memory is not a unitary phenomenon, it should be ideally monitored using a range of tests that reflect theoretical conceptions of the topic. If circumstances demand the use of a single test then a measure of episodic memory is suggested. When it proves only possible to use a rating scale it should be ensured that memory is distinguished from other aspects of cognition and that different types of memory are not confused. The tests used, and the form in which they are used, need to be chosen to be of appropriate difficulty for the sample studied. A major conclusion is that the selection of the measure of memory used in the study of a dietary intervention should never be routine. It is inevitable that the form of the test used will need to be chosen carefully for the population being studied.

What the study of persons at risk for familial Alzheimer's disease can tell us about the earliest stages of the disorder: a review

As the proportion of elderly persons continues to expand, understanding the pathobiology of Alzheimer's disease and being able to diagnose it at an early stage become more critical. A minority of Alzheimer's disease cases are inherited as a fully-penetrant, autosomal dominant trait with a young age of onset. The molecular study of the pathogenic mutations has led to insights regarding the etiology of sporadic Alzheimer's disease. Clinical studies in persons at risk for these mutations have confirmed early episodic memory and executive deficits in Alzheimer's disease and suggested that dysphoria may precede the cognitive changes of Alzheimer's disease. Imaging studies have indicated that medial temporal lobe atrophy begins 3 to 4 years before cognitive symptoms, and quantitative cerebral metabolic changes are also present from early on. Studies of biochemical markers suggest that elevations of plasma A 1-42 occur early in familial Alzheimer's disease but that tau may not be elevated in cerebrospinal fluid until the disease is more advanced.

No spatial working memory deficit in beta-amyloid-exposed rats. A longitudinal study

Two experiments are described assessing whether long-term intraventricular or intrahippocampal administration of beta-amyloid protein 1-40 (beta A1-40) affects spatial working memory in rats monitored in a longitudinal study using the open-field water maze. A delayed matching-to-position procedure (DMTP) was employed in which platform locations were semi-randomly altered between days but were kept constant over the four trials on each day. Intertrial intervals (ITIs) were either 30 s or 1 h between Trials 1 and 2 (all other intervals = 30 s), with Trial 2 performance being an index for spatial working memory. Animals were trained before and tested repeatedly at various intervals after application of various compounds (see below) in five successive test sessions (TSs). In Experiment 1, beta A1-40 was applied after a challenge with long-term oral exposure to aluminium (Al; as 0.1% sulfate in drinking water). This in itself did not affect spatial working memory at any delay, despite of the more than 6 months of intake. beta A1-40 administered alone via intracerebroventricular (icv) minipumps (20 micrograms in 250 microliters) led to a small increase in latencies to find the platform, which recovered to control levels 3 months after minipumps were exhausted. Application of beta A1-40 in Al-exposed animals led to a subtle and progressive decline in working memory. This deterioration was reversed by the nootropic compound nefiracetam, which had no effect on the Al only group. In Experiment 2, well-trained rats were bilaterally implanted with intra-hippocampal minipumps containing beta A1-40 or reverse sequence beta A40-1. This did not impair spatial working memory in the DMTP task, measured either directly after minipumps were exhausted, or 2 weeks later. When intraperitoneally (i.p.) injected with a low concentration of the muscarinic antagonist scopolamine (0.2 mg/kg), a dose that was not effective alone, animals in the beta A1-40 group were amnesic. These data suggest that intra-hippocampal beta A1-40 administration alters cholinergic transmission, but these alterations may be mild and thus do not lead to obvious working memory deficits in a DMTP task in well-trained animals.

Imaging of onset and progression of Alzheimer's disease with voxel-compression mapping of serial magnetic resonance images

BACKGROUND

Early diagnosis and monitoring of the progression of Alzheimer's disease is important for the development of therapeutic strategies. To detect the earliest structural brain changes, individuals need to be studied before symptom onset. We used an imaging technique known as voxel-compression mapping to localise progressive atrophy in patients with preclinical Alzheimer's disease.

METHODS

Four symptom-free individuals from families with early-onset Alzheimer's disease with known autosomal dominant mutations underwent serial magnetic resonance imaging (MRI) over 5-8 years. All four became symptomatic during follow-up. 20 individuals with a clinical diagnosis of probable Alzheimer's disease and 20 control participants also underwent serial MR imaging. A non-linear fluid matching algorithm was applied to register repeat scans onto baseline imaging. Jacobian determinants were used to create the voxel-compression maps.

FINDINGS

Progressive atrophy was revealed in presymptomatic individuals, with posterior cingulate and neocortical temporoparietal cortical losses, and medial temporal-lobe atrophy. In patients with known Alzheimer's disease, atrophy was widespread apart from in the primary motor and sensory cortices and cerebellum, reflecting the clinical phenomenology.

INTERPRETATION

Voxel-compression maps confirmed early involvement of the medial temporal lobes, but also showed posterior cingulate and temporoparietal cortical losses at presymptomatic stage. This technique could be applied diagnostically and used to monitor the effects of therapeutic intervention.

Does longer-term memory storage never become overloaded, and would such overload cause Alzheimer's disease and other dementia?

According to an uncritically accepted axiom, the human brain's capacity for longer-term memory storage is never overloaded. This viewpoint is shown to be contrary to all evidence and beyond reasonable credibility. The entire currently obtainable evidence for or against overload comes via the presence or absence of its manifestation in behaviour. This manifestation would be as an incurable, deteriorating, specific form of memory disorder, associated with old age and consequent to increased data-inputting and reductions of brain capacity. There is in fact such a disorder, namely Alzheimer's disease and other dementia. This relationship provides elegant explanations for various peculiar findings, without encountering any counter-evidence. The premorbid accumulation of tangles in the hippocampus is explained via an integration of existing hippocampus theories. Long-term low doses of drugs that reduce memory formation could prevent or delay dementia. TV-watching, videos, and some memory-enhancing nootropic drugs could increase risk.

The neuropsychology of preclinical Alzheimer's disease and mild cognitive impairment

Subjects in the preclinical stages of Alzheimer's disease (AD) typically record neuropsychological performance between that of healthy older individuals and demented patients. More specifically, deficits on measures of verbal episodic memory are commonly reported in these patients, while other cognitive functions (e.g. language, praxis and executive function) seem to be spared. A similar neuropsychological profile is observed in elderly subjects with mild cognitive impairment (MCI), a disorder that is attracting increasing research interest. Evidence from lesion and functional imaging studies, as well as volumetric imaging in probable AD and MCI patients, suggests that the cognitive deficits observed in these disorders may be related to medial temporal lobe dysfunction. An issue currently under investigation is whether MCI represents the preclinical stages of AD or a distinct and static cognitive aetiology. In an attempt to address this issue, present investigations are adopting a convergent approach to the detection of preclinical AD, where multiple risk factors are considered when making a diagnosis.

Alzheimer's disease due to an intronic presenilin-1 (PSEN1 intron 4) mutation: A clinicopathological study

We describe 21 affected individuals from a kindred with early-onset autosomal dominant familial Alzheimer's disease caused by an intronic presenilin-1 mutation (in intron 4). Mean age at onset of symptoms was 37.4 years [95% confidence interval (CI): 36.6-38.2 years], mean age at death was 44.7 years (95% CI: 43.1-46.3 years) and mean duration of illness was 7.3 years (95% CI: 5.9-8.7 years). Myoclonus and seizures were prominent features of this pedigree. In the four cases for whom neuropsychometric data were available, verbal memory impairment preceded visual memory deficits; naming was relatively preserved until late in the disease. One of these four cases underwent serial volumetric MRI scans demonstrating in vivo brain tissue loss of 3.9% (38.9 ml, annualized rate of atrophy: 1. 7%) over 22 months of follow-up. The four individuals who had necropsies demonstrated the neuropathological hallmarks of Alzheimer's disease. Apolipoprotein E (APOE) status was assessed in five individuals: the case with the youngest age at onset at 33 years of age was found to be homozygous epsilon4/epsilon4, > 1 SD below the mean age of onset for those of known APOE genotype (36.4 +/- 2.3 years, mean +/- SD), and > 2 SDs below the mean age of onset for the pedigree as a whole (37.4 +/- 1.7 years, mean +/- SD). APOE genotype may therefore modulate age at onset in this pedigree.

Magnetoencephalographic analysis of cortical activity in Alzheimer's disease: a pilot study

OBJECTIVES

In the present study, MEG was used to analyze spectral power and reference-free coherence in patients with probable Alzheimer's disease (AD).

METHODS

Sixty-one channel MEG was recorded in 5 AD patients and 5 age-matched controls at rest with eyes open and eyes closed, as well as during the performance of two different mental tasks. Artefact-free epochs were selected for the analysis of power and coherence values in each of 5 4-Hz wide frequency bands ranging from 2 to 22 Hz.

RESULTS

In AD patients, the absolute low frequency magnetic power was significantly and rather diffusely increased relative to controls with a fronto-central maximum. High frequency power values were significantly decreased over the occipital and temporal areas. Reactivity to eye-opening and mental tasks was reduced in the patient group. Relative to controls, a general decrease of MEG coherence values, including all frequencies analyzed, was found in AD patients.

CONCLUSIONS

These observations confirm the pattern of changes in spectral power and reactivity known from EEG studies and suggest that coherence decreases in AD patients are widespread and include frequencies outside the alpha band.

Cognitive impairment in elderly who are not yet demented

Patients with neuropathological changes of Alzheimer disease may not be demented during initial evaluation of memory disturbance. Understanding current issues regarding the patient with incipient degenerative dementia should help identify those at greatest risk for progression and may help delay onset of symptoms.

Mild cognitive impairment--an early stage of Alzheimer's disease?

The hypothesis that mild cognitive impairment (MCI) represents an early stage of Alzheimer's disease (AD) was investigated by reviewing recent research from three sources: asymptomatic and symptomatic individuals carrying mutations that cause AD, hospital-samples of non-demented patients with MCI at the initial examination that are followed longitudinally, and community-based incident cases of AD. Studies with asymptomatic mutation carriers of the amyloid precursor protein and presenilin 1 gene have shown a linear and disease-related decline in most cognitive functions that begins approximately 10 years before the expected clinical onset of AD. However, there is considerable overlap between the level of impairment for mutation carriers and non-carriers of the same age during the early preclinical stage of AD. Hospital-based longitudinal studies have shown that non-demented individuals with isolated mild episodic memory impairment may develop clinically diagnosed AD with widespread cognitive deficits in a few years time. Community-based epidemiological studies on the incidence of AD demonstrate that indices of episodic memory, in addition to measures of general cognitive functioning, are useful in predicting early AD. In contrast, subjective memory impairment or age-associated memory impairment are less powerful predictors of future dementia development. In summary, there is converging evidence to demonstrate that preclinical AD is characterized by a common behavioral phenotype, with cognitive decline in several domains, predominantly in episodic memory. The decline appears to start many years before the clinical onset of AD. Moreover, the progression of the impairment appears to be continuous. Finally, this pattern of performance generalizes across etiology of AD (familial or sporadic), clinical onset (early or late), sample composition (hospital or community), and method of assessment.

A structural basis for memory storage in mammals

It is proposed that altered dendrite length and de novo formation of new dendrite branches in cholinoceptive cells are responsible for long-term memory storage, a process enabled by the degradation of microtubule-associated protein-2. These memories are encoded as modality-specific associable representations. Accordingly, associable representations are confined to cytoarchitectonic modules of the cerebral cortex, hippocampus, and amygdala. The proposed sequence of events leading to long-term storage in cholinoceptive dendrites begins with changes in neuronal activity, then in neurotrophin release, followed by enhanced acetylcholine release, muscarinic response, calcium influx, degradation of microtubule-associated protein-2, and finally new dendrite structure. Hypothetically, each associable representation consists of altered dendrite segments from approximately 5000-15,000 cholinoceptive cells contained within one or a few module(s). Simultaneous restructuring during consolidation of long-term memory is hypothesized to result in a similar infrastructure among dendrite sets, facilitating co-activation of those dendrite sets by neurotransmitters such as acetylcholine, and conceivably enabling high energy interactions between those dendrites by phenomena such as quantum optical coherence. Based on the specific architecture proposed, it is estimated that the human telecephalon contains enough dendrites to encode 50 million associable representations in a lifetime, or put another way, to encode one new associable representation each minute. The implications that this proposal has regarding treatments for Alzheimer's disease are also discussed.

Low education is a genuine risk factor for accelerated memory decline and dementia

A relatively high prevalence and incidence of dementia have been found in population strata with low levels of education in comparison to population strata with high levels of education. However, doubt remains whether this may be an artifact of education bias in the screening tests used. To investigate this matter, we analyzed results of two Dutch population surveys in which unbiased measures of memory decline were used. In the Longitudinal Aging Study Amsterdam (n = 1774) the percentage of words retained in a verbal learning test was found to be disproportionately low in the oldest age cohort (80-85 years) with less than 11 years of education. The Amsterdam Study of the Elderly (n = 4051) found a "dose-response" relationship between education and dementia prevalence. Cross-sectional and longitudinal results showed that, in less educated people, memory decline is faster and sets in at an earlier age. These findings indicate that the relationship between dementia and education is not just an artifact of case detection methods.

Cognitive markers preceding Alzheimer's dementia in the healthy oldest old

OBJECTIVE

To look for preclinical markers of Alzheimer's dementia in a sample of healthy, oldest old individuals.

DESIGN

Prospective, longitudinal study of individuals examined at yearly intervals with neuropsychological tests selected to be sensitive to the early detection of dementia.

PARTICIPANTS

One hundred and thirty-nine community-dwelling, functionally independent, healthy individuals 65 to 106 years of age who met strict criteria for lack of dementia at entry. Incident dementia cases consisted of 16 volunteers all 80 years old or older who developed dementia of the Alzheimer's type and 31 volunteers 80 years old and older showing no evidence of dementia during a mean 2.8-year follow-up interval.

MEASUREMENTS

Scores on 10 neuropsychological measures were analyzed for the initial examination when none of the volunteers showed clinical evidence of dementia and for the two subsequent yearly examinations.

RESULTS

Individuals who subsequently developed dementia showed evidence of verbal memory impairment at their initial examination, which was a mean of 2.8 years before clinical evidence of dementia. The average yearly incidence rate for dementia in those 80 years of age and older was 12%. Performance of individuals who did not development dementia remained relatively stable during follow-up for up to 5 years.

CONCLUSION

Alzheimer's disease has a preclinical stage in which verbal memory decline is the earliest sign. Dementia in the oldest old is distinguishable from age-related cognitive decline.

Visualisation and quantification of rates of atrophy in Alzheimer's disease

BACKGROUND

Definitive diagnosis of Alzheimer's disease requires histological examination of brain tissue. In life, brain atrophy can be visualised by computed tomography or magnetic resonance (MR) imaging, but the atrophy due to the disease is difficult to distinguish from that caused by normal ageing. We have investigated use of accurate positional matching (registration) and digital subtraction of serially acquired MR brain scans to allow determination of rates of global and regional atrophy.

METHODS

This technique was applied to eleven patients with clinically diagnosed Alzheimer's disease and eleven age-matched controls. Each individual had two scans approximately 1 year apart; scan intervals were matched between the groups.

FINDINGS

The median rate of atrophy was significantly greater in the Alzheimer's disease group than in the control group (12.3 [range 5.8 to 23.6] vs 0.3 (-1.2 to 1.7) mL per year; p < 0.0001). There was no overlap between the groups. Furthermore, three non-demented individuals at risk of familial Alzheimer's disease had scans 6-14 months apart and showed greater rates of volume loss than the controls; these three individuals have subsequently developed symptoms.

INTERPRETATION

This technique may be useful for the diagnosis of Alzheimer's disease, the assessment of disease progression, and the evaluation of potential treatments.

Neuropsychological features of early Alzheimer's disease: preclinical and clinical stages

In the preclinical stage of Alzheimer's disease (AD), studies of asymptomatic mutation carriers have identified impairments in episodic memory. Other cognitive functions show no or slight impairment suggesting that preclinical AD is a unifunctional cognitive syndrome; the brain is affected selectively and predominantly in the medial temporal structures. In the early clinical stage, deficits occur in episodic memory, verbal abilities, visuospatial functions, attention, and executive functions. AD becomes a multifunctional cognitive syndrome and the brain's association cortices are affected. Nevertheless, sensory-motor performance and procedural memory seem to be intact and only slight impairment may be seen in primary memory. In advanced AD, cognitive dysfunction including deficits is global in primary memory, although sensory-motor performance may be well preserved. The brain's association cortices are severely affected. The sequence of cognitive decline; from unifunctional to global deficits, conforms to the three-stage development of neurofibrillary tangles described by Braak and Braak.

Neuropsychological assessment

Images

Deficits in cerebral glucose metabolism demonstrated by positron emission tomography in individuals at risk of familial Alzheimer's disease

In order to establish whether positron emission tomography (PET) can identify metabolic changes in Alzheimer's disease at a presymptomatic stage, we have examined 24 asymptomatic at risk individuals from families with Alzheimer's disease. A significant reduction in global cerebral metabolic rate for glucose was found when compared with 16 age-matched controls. There was also a focal, parieto-temporal deficit similar to, although less extensive than, that found in 18 symptomatic individuals from familial Alzheimer's disease (FAD) pedigrees. Follow up of this cohort will establish whether these metabolic changes relate to a presymptomatic stage of the disease.

Catastrophe, chaos and Alzheimer's disease. The F E Williams Lecture

A model can be developed for familial APP mutation Alzheimer's disease to explain why a patient who is cognitively normal until middle age experiences a catastrophic amyloid deposition, which is to some extent mirrored in the clinical deterioration due to a subtle shift in A beta metabolism. However, the analysis of young onset dementia hardly constitutes the study of 'the suffering and infirmities of old age' which F E Williams' bequest is intended to promote. It remains to be seen whether the models relevant to APP mutation FAD can be applied to Alzheimer's disease of old age, or indeed other degenerative diseases of later life. Such models, however, do provide an alternative to the view that Alzheimer's disease is an incremental process virtually indistinguishable from old age itself. With an incremental linear process, treatment is akin to a war of attention. By contrast, with a catastrophic process the difference between a normal elderly person and a patient with incipient Alzheimer's disease at the start may be minimal, perhaps only a few molecules of extended A beta peptide, but they diverge very rapidly. If treatment can be directed at the metabolic events at the onset then there is a real opportunity for optimism. If ultimately successful, prevention rather than delay becomes a realistic goal, echoing Duc de La Rochefoucauld's desire 'to die as young as possible as late as possible'.