Preclinical evidence of Alzheimer's disease in persons homozygous for the epsilon 4 allele for apolipoprotein E

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.

Mitochondrial dysfunction in neurodegeneration

Numerous toxins are known to interfere with mitochondrial respiratory chain functions. Use has been made of these in the development of pesticides and herbicides, and accidental use in man has led to the development of animal models for human disease. The propensity for mitochondrial toxins to induce neuronal cell death may well reflect not only their metabolic pathways but also the sensitivity of neurons to inhibition of oxidative phosphorylation. Thus, the accidental exposure of humans to 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine and to 3-nitropropionic acid had led to primate models of Parkinson's disease and Huntington's Disease, respectively. These models were made all the more remarkable when identical biochemical deficiencies were identified in relevant areas of human suffering from the respective idiopathic diseases. The place of complex I deficiency in Parkinson's disease remains undetermined, but there is recent evidence to suggest that, in some cases at least, it may play a primary role. The complex II/III deficiency in Huntington's disease is likely to be secondary and induced by other pathogenetic factors. The potential to intervene in the cascade of reactions involving mitochondrial dysfunction and cell death offers prospects for the development of new treatment strategies either for neuroprotection in prophylaxis or rescue.

Apolipoprotein E and Alzheimer's disease: a review of recent studies

There are three isoforms of the 33-kDa protein apolipoprotein E (apoE), termed apoE2, apoE3, and apoE4, each encoded by distinct genes APOE2, APOE3 and APOE4, respectively. In 1993, the APOE genotype was identified as a risk factor for Alzheimer's disease (AD) and was subsequently acknowledged to account for approximately 60% of all cases. The influence of the APOE genotype in AD is clearly isoform dependent, APOE4 imparting susceptibility and APOE2 protection. Thus, patients homozygous for the E4 allele show a very strong likelihood of developing the disease by age 75, whereas patients carrying at least one E2 allele are unlikely to develop symptoms of AD by this age. A major issue in AD research is therefore to understand the functional differences between the ApoE isoforms, with the ultimate aim of designing the next generation of drugs to treat this disease. The purpose of the present article is to summarise some of this work. This review encompasses the rapidly developing molecular, cellular and behavioural research into ApoE, and attempts to highlight those findings we consider to be of particular significance.

Anterior cingulate and motor network metabolic impairment in progressive supranuclear palsy

Progressive supranuclear palsy is the prototype of subcortical dementia. Using positron emission tomography and statistical parametric mapping, we compared the glucose metabolic pattern obtained in this subcortical dementia to that observed in elderly healthy controls and in Alzheimer's disease, the prototype of cortical dementia. Progressive supranuclear palsy was characterized by a relative decrease of metabolism in anterior cingulate, adjacent supplementary motor area, precentral cortex, middle prefrontal cortex, midbrain tegmentum, globus pallidus, and ventrolateral and dorsomedial nuclei of thalamus. The data in progressive supranuclear palsy highlight predominant metabolic impairment in brain structures engaged in response selection, in attention for action, and in motor networks.

Amyloid beta-peptide impairs glucose transport in hippocampal and cortical neurons: involvement of membrane lipid peroxidation

A deficit in glucose uptake and a deposition of amyloid beta-peptide (A beta) each occur in vulnerable brain regions in Alzheimer's disease (AD). It is not known whether mechanistic links exist between A beta deposition and impaired glucose transport. We now report that A beta impairs glucose transport in cultured rat hippocampal and cortical neurons by a mechanism involving membrane lipid peroxidation. A beta impaired 3H-deoxy-glucose transport in a concentration-dependent manner and with a time course preceding neurodegeneration. The decrease in glucose transport was followed by a decrease in cellular ATP levels. Impairment of glucose transport, ATP depletion, and cell death were each prevented in cultures pretreated with antioxidants. Exposure to FeSO4, an established inducer of lipid peroxidation, also impaired glucose transport. Immunoprecipitation and Western blot analyses showed that exposure of cultures to A beta induced conjugation of 4-hydroxynonenal (HNE), an aldehydic product of lipid peroxidation, to the neuronal glucose transport protein GLUT3. HNE induced a concentration-dependent impairment of glucose transport and subsequent ATP depletion. Impaired glucose transport was not caused by a decreased energy demand in the neurons, because ouabain, which inhibits Na+/K(+)-ATPase activity and thereby reduces neuronal ATP hydrolysis rate, had little or no effect on glucose transport. Collectively, the data demonstrate that lipid peroxidation mediates A beta-induced impairment of glucose transport in neurons and suggest that this action of A beta may contribute to decreased glucose uptake and neuronal degeneration in AD.

Clinical rationale of genetic testing in dementia

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The genetics of dementia in late life

Recent advances in the genetics of AD and other late-life dementias have provided new insights but also have raised new queries and ethical issues. This review reflects the current state of knowledge in a rapidly evolving field. The complex relation of genes and environment to AD, VaD, and other late-life dementias suggests that the answers to these many issues will evolve through time. New issues undoubtedly will arise as additional genes are discovered and new data accrue that relate APOE and other genes to the mechanism and expression of dementing illness. The clinical relevance and applicability of such research findings will increase when effective treatments become available. Given this potential, we encourage readers to monitor new developments as they arise.

The association between Apo E genotype and depressive symptoms in elderly African-American subjects

In this study of 138 elderly subjects (112 without and 26 with dementia) obtained from a community sample of elderly African-American subjects, there were no significant differences in mean Geriatric Depression Scale scores by Apo E epsilon 4 status for dementia or nondementia subjects. Three subjects received a diagnosis of major depressive disorder. None of these subjects were Apo E epsilon 4-positive. These results do not support an association between depressive symptoms and Apo E allele status in this elderly African-American population.

Neurodegeneration, sleep, and cerebral energy metabolism: a testable hypothesis

Varying degrees of metabolic arrest are used by many living species to survive in a harsh environment. For example, in hibernating mammals, neuronal activity and cerebral metabolism are profoundly depressed in most regions of the brain and limited energy resources are deployed to maintain vital cell functions. Gathering evidence suggests that energy resources are also limited in both Alzheimer's and Parkinson's diseases, and that this promotes metabolic stress and the degenerative process. Key steps in this process are energy requiring, and this further compromises cell energy reserves. It may be possible to slow the progress of these diseases by inducing slow-wave sleep (SWS) at night with gammahydroxybutyrate. Patients with these diseases sleep poorly and generate little SWS. SWS and hibernation are thought to be on a continuum of energy conservation. Thus, the induction of SWS may retard the degenerative process by depressing cell metabolism and by directing energy utilization to vital cell functions. In this way, GHB-induced SWS may duplicate the effects of hibernation and extend biologic time.

Functional imaging of an illusion of pain

Touching warm and cool bars that are spatially interlaced produces a painful burning sensation resembling that caused by intense, noxious cold. We demonstrated previously that this thermal grill illusion can be explained as an unmasking phenomenon that reveals the central inhibition of pain by thermosensory integration. In order to localize this unmasking in the human brain, we have used positron emission tomography (PET) to compare the cortical activation patterns evoked by the thermal grill and by cool, warm, noxious cold and noxious heat stimuli. The thermal grill illusion produces activation in the anterior cingulate cortex, whereas its component warm and cool stimuli do not. This area is also activated by noxious heat or cold. Thus, increased activity in the anterior cingulate cortex appears to be selectively associated with the perception of thermal pain. Disruption of thermosensory and pain integration may account for the central pain syndrome that can occur after stroke damage.

The Alzheimer diseases

Our understanding of the etiologies of the Alzheimer diseases is advancing rapidly, led by the discovery of relevant genetic mutations for autosomal-dominant forms of the disease and widespread confirmation of the role played by apolipoprotein E, the major susceptibility gene for the common form of Alzheimer's disease. New hypotheses are being generated and old hypotheses are being modified to account for the wealth of new information.

Metabolic coupling between glia and neurons

The coupling between synaptic activity and glucose utilization(neurometabolic coupling) is a central physiological principle of brain function that has provided the basis for 2-deoxyglucose-based functional imaging with positron emission tomography (PET). Astrocytes play a central role in neurometabolic coupling, and the basic mechanism involves glutamate-stimulated aerobic glycolysis; the sodium-coupled reuptake of glutamate by astrocytes and the ensuing activation of the Na-K-ATPase triggers glucose uptake and processing via glycolysis, resulting in the release of lactate from astrocytes. Lactate can then contribute to the activity-dependent fuelling of the neuronal energy demands associated with synaptic transmission. An operational model, the `astrocyte–neuron lactate shuttle', is supported experimentally by a large body of evidence,which provides a molecular and cellular basis for interpreting data obtained from functional brain imaging studies. In addition, this neuron–glia metabolic coupling undergoes plastic adaptations in parallel with adaptive mechanisms that characterize synaptic plasticity. Thus, distinct subregions of the hippocampus are metabolically active at different time points during spatial learning tasks, suggesting that a type of metabolic plasticity,involving by definition neuron–glia coupling, occurs during learning. In addition, marked variations in the expression of genes involved in glial glycogen metabolism are observed during the sleep–wake cycle, with in particular a marked induction of expression of the gene encoding for protein targeting to glycogen (PTG) following sleep deprivation. These data suggest that glial metabolic plasticity is likely to be concomitant with synaptic plasticity.