Inflammatory markers in younger vs elderly normal volunteers and in patients with Alzheimer's disease

Markers of inflammation and cognitive decline in an African-Caribbean population

BACKGROUND

Inflammatory processes may play an important role in cognitive decline and dementia. We investigated the prospective association between levels of three markers of inflammation, plasma interleukin-6 (IL-6), serum C-reactive protein (CRP), serum amyloid A (SAA), and cognitive decline in an African-Caribbean community population.

METHODS

Of 290 participants aged 55-75 years at baseline sampled from Primary Care registration lists in south London, 216 (75%) were re-interviewed after 3 years. Baseline plasma concentrations of IL-6, CRP and SAA were ascertained through immunoassays. A battery of psychometric tests was administered on both occasions and decline in both individual tests and a composite outcome was analysed.

RESULTS

After adjustment for potential confounding factors, raised levels of IL-6 (>3.1 pg/ml) were associated with cognitive decline in the total sample (odds ratio 2.9, 95% CI 1.1-7.5), but no associations were found for CRP or SAA. Raised IL-6 was most strongly associated with decline in orientation and immediate verbal recall tasks, with weaker associations for delayed recall and psychomotor speed.

CONCLUSIONS

Raised IL-6 but not CRP predicted cognitive decline in this population Inflammatory changes associated with cognitive decline may be specific to particular causal pathways.

Admission albumin levels and functional outcome of elderly hip fracture patients: is it that important?

BACKGROUND AND AIMS

Low serum albumin level is considered a marker of poor health outcome in various medical conditions. A relationship between low albumin levels and poor functional outcome has been found in the elderly, lower albumin predicting a greater functional decline. The objective of this study was to evaluate to what extent admission albumin levels may affect the functional outcome of elderly hip fracture patients.

METHODS

This retrospective chart review study was conducted in an orthogeriatric unit of a university-affiliated referral hospital. The participants were 449 elderly patients with hip fractures, admitted for a standard rehabilitation course. Functional outcome of patients with normo-albuminemia and hypo-albuminemia was assessed by Functional Independence Measurement (FIM) at admission and discharge. Data were analyzed by t-test, Pearson's correlation, Chi-square test and Linear Regression.

RESULTS

38.8% of patients were hypoalbuminemic upon admission. These patients were older (p<0.001) and had lower Mini-Mental State Examination (MMSE) scores (p=0.003), compared with normo- albuminemic patients. Discharge FIM scores were higher in normo-albuminemic compared with hypo-albuminemic patients (total FIM 86.1+/-23.9 and 77.0+/-26.4, respectively; p<0.001; motor-FIM 60.0+/-16.3 and 53.4+/-18.0, respectively; p<0.001). Linear regression analysis showed that total FIM at discharge was inversely associated with pre-fracture function (beta -0.13; p<0.001). A high MMSE score (beta 0.16; p<0.001), female gender (beta 0.05; p=0.02) and higher admission total FIM scores (beta 0.69; p<0.001) emerged as predictors of higher total FIM scores upon discharge. Albumin levels did not independently predict better total FIM scores upon discharge (beta -0.02; p=0.36).

CONCLUSIONS

Normo-albuminemic patients present with better admission FIM scores and have higher discharge FIM scores. After controlling for possible confounders, albumin remains a non-significant predictor of higher discharge FIM scores. We suggest that low albumin levels should not be considered as adversely affecting the rehabilitation of elderly hip fracture patients.

Taste acuity in response to zinc supplementation in older Europeans

Taste acuity declines with age and may be dependent upon Zn status. The aim of the present double-blind, randomised controlled intervention trial has been to determine taste acuity in response to Zn supplementation (placebo, or 15 or 30 mg Zn/d). Healthy older European adults aged 70–87 years were recruited within Italy (Rome) (n 108) and France (Grenoble) (n 91) to the European Commission-funded Zenith project. A signal detection theory approach was adopted for taste assessment. The data were converted to R indices and analysed by repeated-measures ANOVA controlling for baseline taste acuity as well as serum and erythrocyte Zn. Serum Zn increased post-intervention, indicating compliance with the intervention. Results differed across geographical region. Salt taste acuity was greater in response to Zn (30 mg) than placebo post-intervention among those recruited in Grenoble. There was no apparent change in acuity for sweet, sour or bitter taste in response to Zn. Supplemented Zn may have potential to enhance salt taste acuity in those over the age of 70 years. Further research is required to determine if enhanced salt taste acuity is reflected in the eating experiences of older individuals.

Induction of the formyl peptide receptor 2 in microglia by IFN-gamma and synergy with CD40 ligand

Human formyl peptide receptor (FPR)-like 1 (FPRL1) and its mouse homologue mFPR2 are functional receptors for a variety of exogenous and host-derived chemotactic peptides, including amyloid beta 1-42 (Abeta(42)), a pathogenic factor in Alzheimer's disease. Because mFPR2 in microglial cells is regulated by proinflammatory stimulants including TLR agonists, in this study we investigated the capacity of IFN-gamma and the CD40 ligand (CD40L) to affect the expression and function of mFPR2. We found that IFN-gamma, when used alone, induced mFPR2 mRNA expression in a mouse microglial cell line and primary microglial cells in association with increased cell migration in response to mFPR2 agonists, including Abeta(42). IFN-gamma also increased the endocytosis of Abeta(42) by microglial cells via mFPR2. The effect of IFN-gamma on mFPR2 expression in microglial cells was dependent on activation of MAPK and IkappaB-alpha. IFN-gamma additionally increased the expression of CD40 by microglial cells and soluble CD40L significantly promoted cell responses to IFN-gamma during a 6-h incubation period by enhancing the activation of MAPK and IkappaB-alpha signaling pathways. We additionally found that the effect of IFN-gamma and its synergy with CD40L on mFPR2 expression in microglia was mediated in part by TNF-alpha. Our results suggest that IFN-gamma and CD40L, two host-derived factors with increased concentrations in inflammatory central nervous system diseases, may profoundly affect microglial cell responses in the pathogenic process in which mFPR2 agonist peptides are elevated.

Systemic and acquired immune responses in Alzheimer's disease

Alzheimer's disease (AD) is a neurodegenerative disorder characterized clinically by a progressive cognitive decline and dementia. AD brains are marked by amyloid plaques and neurofibrillary tangles, neuronal cell loss, and a prominent activation of glial cells, and innate immune responses. A growing number of studies in AD have also reported alterations in systemic immune responses including changes in lymphocyte and macrophage distribution and activation, the presence of autoantibodies, or abnormal cytokine production. Studies in animal models for AD support the notion that immune cells infiltrate the brain and may modulate the disease. Here we will review evidence for systemic alterations in immune responses and a role for acquired immunity in AD and discuss their potential contribution to the disease.

Alterations in peripheral blood lymphocyte cytokine expression in obesity

Obesity is characterized by alterations in immune and inflammatory function. In order to evaluate the potential role of cytokine expression by peripheral blood mononuclear cells (PBMC) in obesity-associated inflammation, we studied serum protein levels and mRNA levels in PBMC of interleukin (IL)-6, IL-1beta, tumour necrosis factor (TNF)-alpha and IL-1Ra in nine lean and 10 obese subjects. Serum IL-1beta was undetectable, IL-1Ra serum levels were elevated, serum levels of TNF-alpha were decreased and serum levels of IL-6 were similar in obese subjects compared to lean subjects, while transcript levels of IL-6, IL-1beta and TNF-alpha, but not IL-1Ra, were decreased in PBMC from obese subjects. PBMC from obese subjects did, however, up-regulate cytokine expression in response to leptin. Thus, obesity-associated changes in IL-1Ra serum levels and IL-6 mRNA levels were not correlated with changes in cognate mRNA and serum levels, respectively, while TNF-alpha serum levels and PBMC mRNA levels were both decreased in obese patients. While immune alterations in obesity are manifest in peripheral blood lymphocytes, the general lack of correlation between altered serum levels and altered PBMC gene expression suggests that PBMC may not be the source of aberrant serum cytokine levels in obesity.

CKBM stimulates MAPKs but inhibits LPS-induced IFN-gamma in lymphocytes

CKBM is an herbal formula composed of five Chinese medicinal herbs (Panax ginseng, Schisandra chinensis, Fructus crataegi, Ziziphus jujuba and Glycine max) supplemented with processed Saccharomyces cerevisiae. It has been demonstrated that CKBM is capable of triggering the release of IL-6 and TNFalpha from human peripheral blood mononuclear cells. In this report, T-lymphocytic Sup-T1 cells and B-lymphocytic Ramos cells were utilized as cellular models to investigate how CKBM regulates intracellular signaling as well as the production of cytokines. CKBM stimulated the three major subgroups of mitogen-activated protein kinase (i.e. ERK, JNK and p38) in Sup-T1 cells, but only triggered the activation of ERK and p38 in Ramos cells. The induction of mitogen-activated protein kinases (MAPK) activations varied with the duration of treatment, as well as with the dosage of CKBM. In terms of cytokine production, treatment of CKBM alone did not trigger the release of IL-1beta and IFNgamma, but it suppressed the LPS-induced IFNgamma production from both Sup-T1 cells and Ramos cells. In view of the therapeutic effects of traditional Chinese medicines in inflammatory and autoimmune disorders, the results suggest that CKBM may exhibit its immuno-modulatory effects by regulating intracellular signaling as well as cytokine production in different lymphocytic cell types.

Circulating biomarkers of cognitive decline and dementia

Plasma and serum biochemical markers proposed for cognitive decline of degenerative (Alzheimer's disease, AD) or vascular origin and predementia syndromes (mild cognitive impairment and other related entities) are based on pathophysiologic processes such as lipoprotein metabolism (total cholesterol, apolipoprotein E, 24S-hydroxy-cholesterol), and vascular disease (homocysteine, lipoprotein(a)); SP formation (amyloid beta(Abeta)-protein, Abeta autoantibodies, platelet APP isoforms), oxidative stress (isoprostanes, vitamin E), and inflammation (cytokines). This review will focus on the current knowledge on circulating serum and plasma biomarkers of cognitive decline and dementia that are linked to cholesterol homeostasis and lipoprotein abnormalities, senile plaque formation and amyloid precursor protein (APP) metabolism, oxidative stress, and inflammatory reactions. Special emphasis will, however, be placed on biomarkers related to lipoprotein metabolism and vascular disease. Analytically, most plasma and serum proteins or metabolites lack reproducibility, sensitivity, or specificity for the diagnosis, risk and progression assessment, or therapeutic monitoring of AD and other dementing disorders. Measures linked to lipoprotein metabolism and vascular disease, APP metabolism, oxidative stress, or inflammation appear altered in AD relative to controls, but lack sufficient discriminatory power. Measures combining several biomarkers or incorporating a range of proteins in plasma and small molecule metabolites are promising approaches for the development of plasma or serum-based diagnostic tests for AD and other dementing disorders, as well as for predementia syndromes.

Zinc status and taste acuity in older Europeans: the ZENITH study

BACKGROUND

Age-related decline in taste acuity may be both a cause and an effect of depleted zinc and/or increased zinc requirement.

OBJECTIVE

The aim of this study was to explore associations between zinc status and taste acuity in healthy older European adults aged 55-90 y.

SAMPLE

Volunteers were recruited within Italy (n = 108 aged 70-90 y), the United Kingdom (UK) (n = 93 aged 55-70) and two regions of France (n = 186), Grenoble (aged 70-90 y) and Clermont-Ferrand (aged 55-70 y).

METHODS

A signal detection theory approach was adopted, employing a three-alternative, forced-choice procedure. The data were converted to R-indices and bivariate correlations were computed to explore relationships between serum zinc, erythrocyte zinc and taste acuity. ANOVA was undertaken to determine regional differences in zinc status.

RESULTS

Higher erythrocyte zinc status was associated with better acuity for salt (sodium chloride) taste in the sample as a whole (P = 0.012) (n = 385). Higher serum zinc levels were associated with greater sensitivity to sour taste (citric acid) (P = 0.015) only in the older groups (aged 70-90 y). There were no apparent associations between serum or erythrocyte zinc status and acuity for bitter (quinine) or sweet (sucrose) tastes irrespective of age.

CONCLUSION

These results agree with those previously suggesting that age-related detriment in sensitivity for salt taste may be associated with depleted zinc.

Brain, aging and neurodegeneration: role of zinc ion availability

Actual fields of research in neurobiology are not only aimed at understanding the different aspects of brain aging but also at developing strategies useful to preserve brain compensatory capacity and to prevent the onset of neurodegenerative diseases. Consistent with this trend much attention has been addressed to zinc metabolism. In fact, zinc acts as a neuromodulator at excitatory synapses and has a considerable role in the stress response and in the functionality of zinc-dependent enzymes contributing to maintaining brain compensatory capacity. In particular, the mechanisms that modulate the free zinc pool are pivotal for safeguarding brain health and performance. Alterations in zinc homeostasis have been reported in Parkinson's and Alzheimer's disease as well as in transient forebrain ischemia, seizures and traumatic brain injury, but little is known regarding aged brain. There is much evidence that that age-related changes, frequently associated to a decline in brain functions and impaired cognitive performances, could be related to dysfunctions affecting the intracellular zinc ion availability. A general agreement emerges from studies of humans' and rodents' old brains about an increased expression of metallothionein (MT) isoforms I and II, but dyshomogenous results are reported for MT-III, and it is still uncertain whether these proteins maintain in aging the protective role, as it occurs in adult/young age. At the same time, there is considerable evidence that amyloid-beta deposition in Alzheimer's disease is induced by zinc, but the pathological significance and the causes of this phenomenon are still an open question. The scientific debate on the role of zinc and of some zinc-binding proteins in aging and neurodegenerative disorders, as well as on the beneficial effect of zinc supplementation in aged brain and neurodegeneration, is extensively discussed in this review.

Effects of serotonin and serotonergic agonists and antagonists on the production of tumor necrosis factor alpha and interleukin-6

Serotonin (5-HT) is a neurotransmitter and immune modulator. The effect of 5-HT on the production of cytokines by human macrophages and lymphocytes is poorly recognized. In the present article we examine the role of 5-HT in modulating the production of two pro-inflammatory cytokines, i.e. interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNFalpha), as well as the role of 5-HT(1A) and 5-HT(2) receptors in this process. The specific aims were to examine the effects of 5-HT, p-chlorophenylalanine (PCPA), a 5-HT depleting agent, flesinoxan, a 5-HT(1A) agonist, m-chlorophenylpiperazine (mCPP), a 5-HT(2B/2C) agonist, and ritanserin, a 5-HT(2A/2C) antagonist, on the production of the above cytokines. We found that: (1) 5-HT, 15 microg/ml, significantly decreased IL-6 and TNFalpha production; (2) pCPA, 5 microM, significantly suppressed the production of IL-6 and TNFalpha; and (3) mCPP, 2.7 microg/ml, significantly increased the production of IL-6 and TNFalpha. It is concluded that intracellular 5-HT is necessary for optimal synthesis of IL-6 and TNFalpha; 5-HT in physiological concentrations may increase IL-6 and TNFalpha production by stimulating 5-HT(2) receptors; and extracellular 5-HT concentrations above the baseline physiological levels may suppress the production of the above cytokines.

Biomarkers of Alzheimer disease in plasma

Plasma and serum biochemical markers proposed for Alzheimer disease (AD) are based on pathophysiologic processes such as amyloid plaque formation [amyloid beta-protein (A beta), A beta autoantibodies, platelet amyloid precursor protein (APP) isoforms], inflammation (cytokines), oxidative stress (vitamin E, isoprostanes), lipid metabolism (apolipoprotein E, 24S-hydroxycholesterol), and vascular disease [homocysteine, lipoprotein (a)]. Most proteins or metabolites evaluated in plasma or serum thus far are, at best, biological correlates of AD: levels are statistically different in AD versus controls in some cohorts, but they lack sensitivity or specificity for diagnosis or for tracking response to therapy. Approaches combining panels of existing biomarkers or surveying the range of proteins in plasma (proteomics) show promise for discovering biomarker profiles that are characteristic of AD, yet distinct from nondemented patients or patients with other forms of dementia.

Combination of serum markers related to several mechanisms in Alzheimer's disease

Alzheimer's disease (AD) probably involves several pathobiochemical mechanisms and this may be reflected by changes in different serum components. The present study investigated whether the combined analysis of serum molecules related to different mechanisms improves the discrimination of AD patients from healthy controls. Serum of patients with AD was analyzed for a broad spectrum of marker molecules, including 11 inflammatory proteins, 12 sterol intermediates and phytosterols, 2 brain-specific proteins and 4 constituents involved in homocysteine homeostasis. The serum molecule concentrations were combined in a logistic regression model, using a forward stepwise inclusion mode. The results showed that the combination of interleukin-6 (IL-6) receptor, protein alpha1 fraction, cysteine and cholesterol concentrations improved the discrimination between AD patients and healthy controls compared to the single markers. In conclusion, the results of this study have shown that the complex pathology in AD is reflected in a pattern of altered serum concentrations of several marker molecules related to several pathobiochemical mechanisms.

Interleukin-6 gene alleles affect the risk of Alzheimer's disease and levels of the cytokine in blood and brain

Two different polymorphic regions of the interleukin-6 (IL-6) gene were investigated in patients with Alzheimer's disease (AD) and non-demented controls. The -174 C allele in the promoter region of IL-6 gene was over-represented in AD patients compared to controls and significantly increased the risk of AD. Moreover, the -174 CC genotype was associated with a high risk of the disease in women. The D allele of a variable number of tandem repeat (VNTR) was in strong linkage disequilibrium with the -174 C allele and slightly increased AD risk. On the other hand, the frequency of the VNTR C allele was decreased in patients with AD and was negatively associated with the risk of developing AD. Both the -174 CC and VNTR DD genotypes were also associated with increased IL-6 levels in the blood and brain from AD. These findings suggest that IL-6 may play a multifaceted role in AD by affecting the turnover of the cytokine.

The induction of the TNFalpha death domain signaling pathway in Alzheimer's disease brain

The tumor necrosis factor-alpha death domain pathway contributes to cellular degeneration in a variety of conditions. This study investigates the hypothesis that this death domain pathway is progressively induced in the brain during the progression of Alzheimer's disease (AD). AD cases had increased levels of proapoptotic markers including tumor necrosis factor-alpha (TNFalpha), TNF receptor type 1 (TNF-R1), TNF receptor-associated death domain (TRADD), and caspase-3, 2- to 10-fold higher (P < .01) than age-matched controls and 1 to 3 times higher than transitional cases. In striking contrast, potentially neuroprotective TNF receptor type 2 (TNF-R2), and Fas-associated death domain-like interleukin-1beta-converting enzyme (FLICE) inhibitor protein (FLIP) were decreased in AD as compared with age-matched control cases (P < .01). Overall, there was an elevation in proapoptotic elements, including a 5-fold increase in TNF-R1 and a 12-fold decrease in FLIP in AD brains. These changes may translate to increased degenerative potential because the downstream effector caspase-3 and product of the TNF pathway was also increased in parallel with enhanced TNF proapoptotic conditions. Our findings suggest that the TNF death receptor pathway and caspases are activated in the early stages of neuronal degeneration in AD.

Peripheral inflammatory response in Alzheimer's disease and multiinfarct dementia

Whether peripheral inflammatory molecules can be considered markers of dementia is still an open issue. We have investigated the presence of circulating cytokines and the ability of blood cells to release them in response to an inflammatory stimulus in patients with different types of dementia and in age-matched controls. A significant increase in circulating interleukin-1beta in moderate Alzheimer and in multiinfarct (145 and 224 times control concentration, respectively) dementia and in circulating tumor necrosis factor-alpha concentration in multiinfarct dementia patient group (156%) were found. Tumor necrosis factor-alpha and interleukin-6 released from blood cells after exposure to lipopolysaccharide were significantly reduced in moderate Alzheimer (60%, both cytokines) and multiinfarct patients (71 and 50%, respectively), while interleukin-10 was decreased only in multiinfarct patients (61%). The results show that patients with Alzheimer disease or multiinfarct dementia have an upregulation of circulating cytokines and a downregulation of cytokines released by blood cells.

Immunological mechanisms and the spectrum of psychiatric syndromes in Alzheimer's disease

Pathological, genetic and epidemiological studies support the opinion that inflammatory mechanisms are involved in the pathogenesis of Alzheimer's disease (AD). Recent pathological and neuroradiological (PET) data show that activation of microglia is an early pathogenic event that precedes the process of severe neuropil destruction in AD brains. In this paper we review the evidence that inflammatory mediators can play a pathogenic role in some behavioural disorders frequently encountered during the clinical course in AD patients. Motivational disturbances are the most striking of the depressive symptoms in AD and can be present in a preclinical stage of the disease. Experimental animal studies and clinical trials in humans have shown that cytokines can induce similar symptoms which were described as 'sickness behaviour' or 'depressive-like' state. Delirious states are frequently observed in more advanced stages of dementia. Delirium is generally considered the result of an imbalance in neurotransmitter systems with severe deficits of the cholinergic systems. Animal studies show that pro-inflammatory cytokines, such as interleukin-1, induce a reduced activity of the cholinergic system. In AD, the release of cytokines would exacerbate any already existing disturbances in the cholinergic neurotransmission. This could explain the susceptibility of demented patients to delirium provoked by a wide variety of trivial incidents that are accompanied by an acute phase response. The data reviewed in this paper suggest that it could be worthwhile employing a neuroimmunological approach to study at molecular level the pathogenesis of a broad spectrum of behavioural disturbances common in the clinical course of AD patients.

Androgen receptor-mediated inhibition of cutaneous wound healing

Impaired wound healing states in the elderly lead to substantial morbidity, mortality, and a cost to the US Health Services of over $9 billion per annum. In addition to intrinsic aging per se causing delayed healing, studies have suggested marked sex-differences in wound repair. We report that castration of male mice results in a striking acceleration of local cutaneous wound healing, and is associated with a reduced inflammatory response and increased hair growth. Using a hairless mouse model, we have demonstrated that testosterone reduction stimulates the healing response not through hair follicle epithelial/mesenchymal cell proliferation, but directly via effects on wound cell populations. We suggest that endogenous testosterone inhibits the cutaneous wound healing response in males and is associated with an enhanced inflammatory response. The mechanisms underlying the observed effects involve a direct upregulation of proinflammatory cytokine expression by macrophages in response to testosterone. Blockade of androgen action systemically, via receptor antagonism, accelerates healing significantly, suggesting a specific target for future therapeutic intervention in impaired wound healing states in elderly males.

Association between the TNFalpha-308 A/G polymorphism and the onset-age of Alzheimer disease

Local inflammatory processes associated with amyloid plaques would contribute to the progression of late-onset Alzheimer disease (LOAD). Tumor necrosis factors alpha (TNF(alpha)) and beta (LT(alpha)) are inflammatory cytokines involved in the local immune response occurring in the central nervous system of LOAD patients. Genetic variation at these genes could contribute to the risk of developing AD or influence the age at the onset of the disease. We genotyped 315 LOAD patients and 400 healthy controls for DNA-polymorphisms in the genes encoding TNF(alpha) (-308 G/A, -238G/A) and LT(alpha) (Asn26Thr). Carriers of -308A showed a mean age at onset 3 years younger than noncarriers of this allele (P = 0.019). Our data suggest an effect of the TNF(alpha)-308 polymorphism on the age at onset of late AD. This represents additional evidence of the importance of genetic variation at the proinflammatory components in the origin and progression of this common neurodegenerative disease.

Biochemical markers related to Alzheimer's dementia in serum and cerebrospinal fluid

The diagnosis of Alzheimer's disease (AD) is currently based on clinical and neuropsychological examination. To date there is no blood test available that can discriminate dementia patients from healthy individuals. In the present paper, an overview of the current state of knowledge on biologic markers in serum (plasma) and CSF is presented. The combination of characteristic plaque markers tau and amyloid bèta may constitute a specific and sensitive CSF marker for AD. Glial fibrillary acidic protein and antibodies in CSF may be a marker for severe neurodegeneration. CSF concentrations of the oxidative stress markers 3-nitrotyrosine, 8-hydroxy-2'-deoxyguanosine and isoprostanes are increased in AD patients. Serum 24S-OH-cholesterol may be an early whereas glial fibrillary acidic protein autoantibody level may be a late marker for neurodegeneration. To date, serum alpha(1)-Antichymotripsin concentration is the most convincing marker for CNS inflammation. Increased serum homocysteine concentrations have also been consistently reported in AD. In summary, a large overlap in mean concentrations has been observed in studies comparing AD patients with healthy controls for single markers. These studies together support the theory of testing several serum markers in combination for the diagnosis of AD.

Antioxidant strategies for Alzheimer's disease

Oxidative damage is present within the brains of patients with Alzheimer's disease (AD), and is observed within every class of biomolecule, including nucleic acids, proteins, lipids and carbohydrates. Oxidative injury may develop secondary to excessive oxidative stress resulting from beta-amyloid-induced free radicals, mitochondrial abnormalities, inadequate energy supply, inflammation or altered antioxidant defences. Treatment with antioxidants is a promising approach for slowing disease progression to the extent that oxidative damage may be responsible for the cognitive and functional decline observed in AD. Although not a uniformly consistent observation, a number of epidemiological studies have found a link between antioxidant intake and a reduced incidence of dementia, AD and cognitive decline in elderly populations. In AD clinical trials molecules with antioxidant properties such as vitamin E and Ginkgo biloba extract have shown modest benefit. A clinical trial with vitamin E is currently ongoing to determine if it can delay progression to AD in individuals with mild cognitive impairment. Combinations of antioxidants might be of even greater potential benefit for AD, especially if the agents worked in different cellular compartments or had complementary activity (e.g. vitamins E, C and ubiquinone). Naturally-occurring compounds with antioxidant capacity are available and widely marketed (e.g. vitamin C, ubiquinone, lipoic acid, beta-carotene, creatine, melatonin, curcumin) and synthetic compounds are under development by industry. Nevertheless, the clinical value of these agents for AD prevention and treatment is ambiguous, and will remain so until properly designed human trials have been performed.