Apolipoprotein E Genotype and Sex Risk Factors for Alzheimer Disease: A Meta-analysis

Amyloid and Tau Pathology in Cognitively Unimpaired Individuals With a Parental History of Alzheimer Disease: Role of Sex and Parent's Sex

BACKGROUND AND OBJECTIVES

Female sex and a parental history of Alzheimer disease (AD), especially maternal, confer increased risk of AD. Associations between sex, or affected AD parent's sex, and biomarkers of AD are less clear. We examined whether sex or affected AD parent's sex influences (1) β-amyloid (Aβ) and tau burden/accumulation, (2) the association between Aβ and tau burden, and (3) brain and cognitive resilience to Aβ and tau burden.

METHODS

The sample included 243 participants from the Presymptomatic Evaluation of Experimental or Novel Treatments for AD cohort in Canada. All participants with [18F]-NAV4694 and [18F]-AV1451 PET and MRI were included. We examined (1) sex or affected AD parent's sex differences on regional Aβ and tau burden/accumulation; (2) 2-way interactions between sex, or affected AD parent's sex, and Aβ on tau burden; and (3) 3-way interactions between time, sex or affected AD parent's sex, and Aβ or tau deposition on hippocampal volume (brain resilience) and cognition (cognitive resilience) over time.

RESULTS

Participants (69.4% female) were aged 68.3 ± 5.1 years at their first PET scans. All were cognitively unimpaired at baseline. Longitudinal cognitive data were available for 242 participants (follow-up, 6.72 ± 2.38 years), including 238 (6.53 ± 2.48 years of follow-up) with MRI follow-ups and 115 (4.4 ± 0.6 years of follow-up) with PET follow-ups, and 71 developed mild cognitive impairment. Women showed greater tau deposition (standardized β = 0.13 ± 0.3) and showed a stronger association between global Aβ and tau deposition than men (standardized β = 0.79 ± 0.1). Individuals with an affected AD father showed stronger association between global Aβ and tau deposition than those with an affected AD mother (standardized β = 0.65 ± 0.1). Women showed less Aβ-associated hippocampal atrophy over time (standardized β = 0.24 ± 0.1).

DISCUSSION

Women and, surprisingly, individuals with a paternal history of AD seemed more vulnerable to the Aβ-related spread of tau, whereas women showed greater brain resilience to Aβ. Understanding sex-specific risk and resilience could allow more clinical trial precision and personalization. A major limitation included the reduced sample for the affected AD parent's sex analyses.

Unlocking the therapeutic promise of miRNAs in promoting amyloid-β clearance for Alzheimer's disease

Alzheimer's disease (AD) is a neurological disorder that affects cognition and behavior, accounting for 60-70 % of dementia cases. Its mechanisms involve amyloid aggregates, hyperphosphorylated tau tangles, and loss of neural connections. Current treatments have limited efficacy due to a lack of specific targets. Recently, microRNAs (miRNAs) have emerged as key modulators in AD, regulating gene expression through interactions with mRNA. Dysregulation of specific miRNAs contributes to disease progression by disrupting clearance pathways. Antisense oligonucleotide (ASO)-based therapies show promise for AD treatment, particularly when combined with miRNA mimics or antagonists, targeting complex regulatory networks. However, miRNAs can interact with each other, complicating cellular processes and potentially leading to side effects. Our review emphasizes the role of miRNAs in regulating amyloid-beta (Aβ) clearance and highlights their potential as therapeutic targets and early biomarkers for AD, underscoring the need for further research to enhance their efficacy and safety.

APOE ε4 influences the dynamic functional connectivity variability and cognitive performance in Alzheimer's disease

BackgroundApolipoprotein E (APOE) ε4 is the most significant genetic risk factor for sporadic Alzheimer's disease (AD). However, its impact on the dynamic changes in resting-state functional connectivity (FC), particularly concerning network formation, interaction, and dissolution over time, remains largely unexplored in AD.ObjectiveThis study aims to explore the effect of APOE ε4 on dynamic FC (dFC) variability and cognitive performance in AD.MethodsWe analyzed the dFC of AD patients, comparing APOE ε4 carriers (n = 33) with non-carriers (n = 41). The whole-brain dFC was assessed by calculating dynamic fractional amplitude of low-frequency fluctuations (dfALFF) and dynamic regional homogeneity (dReHo). To further explore the relationship between cognitive function and dFC in AD patients, we conducted a correlation analysis. Mediation analysis was also performed to determine whether dFC mediates the link between the APOE ε4 and cognitive decline in AD patients.ResultsAD patients carrying the APOE ε4 exhibited more severe cognitive impairment, along with reduced dReHo and dfALFF in both the left and right posterior cerebellar lobes. In these carriers, the dFC analysis showed lower dFC between the left posterior cerebellar lobe and the left middle temporal gyrus, which was positively correlated with executive function and information processing speed. Additionally, mediation analysis indicated that APOE ε4 influences dFC in this brain region, contributing to executive dysfunction in AD.ConclusionsThese findings offer preliminary evidence that APOE ε4 modulates fluctuating communication within the cerebellar lobe and the dFC between the cerebellar lobe and the temporal gyrus in AD.

The global, regional, and national burdens of dementia in 204 countries and territories from 1990 to 2021: A trend analysis based on the Global Burden of Disease Study 2021

The global population is aging, and as a consequence, the prevalence of dementia is increasing rapidly. This study aims to analyze trends in the Global Burden of Disease (GBD) and health inequalities for dementia over the period 1990 to 2021. The incidence, prevalence, and disability-adjusted life year rates of dementia in the GBD 2021 database were analyzed at the global, national, and regional levels for the period 1990 to 2021 using Joinpoint 4.9.1.0 software. The trends over the period were assessed using a combination of age-standardized rates, average annual percentage changes (AAPCs), and a sociodemographic index. The analysis revealed that, from 1990 to 2021, the global AAPC in dementia incidence, prevalence, and disability-adjusted life years amounted to 0.06 (95% confidence interval [CI]: 0.05-0.09), 0.09 (95% CI: 0.08-0.10), and 0.03 (95% CI: 0.01-0.05), respectively. Conversely, the mean AAPC in age-standardized mortality rate remained stable at 0 (95% CI: -0.02 to 0.03). The age-standardized incidence rate and age-standardized prevalence rate of dementia exhibited a positive association with sociodemographic index during the study period. The 3 regions with the highest mean AAPC in age-standardized mortality rate among the 21 GBD regions were South Africa, Central Sub-Saharan Africa, and Eastern Sub-Saharan Africa. The findings of the study indicate that the burden of dementia increases with age and is projected to remain on an upward trend until 2040. The GBD has increased significantly from 1990 to 2021, and the prevention and control of dementia represents a long-term and formidable challenge.

Sex differences in age-associated neurological diseases-A roadmap for reliable and high-yield research

Once taken into consideration, sex differences in neurological diseases emerge in abundance: (i) Stroke severity is significantly higher in females than in males, (ii) Alzheimer's disease (AD) pathology is more pronounced in females, and (iii) conspicuous links with hormonal cycles led to female-specific diagnoses, such as catamenial migraines and epilepsy. While these differences receive increasing attention in isolation, they likely link to similar processes in the brain. Hence, this review aims to present an overview of the influences of sex chromosomes, hormones, and aging on male and female brains across health and disease, with a particular focus on AD and stroke. The focus here on advancements across several fields holds promise to fuel future research and to lead to an enriched understanding of the brain and more effective personalized neurologic care for all.

Serum proteomics reveals early biomarkers of Alzheimer's disease: The dual role of APOE-ε4

Alzheimer's disease (AD), the leading cause of dementia, significantly impacts global public health, with cases expected to exceed 150 million by 2050. Late-onset Alzheimer's disease (LOAD), predominantly influenced by the APOE-ε4 allele, exhibits complex pathogenesis involving amyloid-β (Aβ) plaques, neurofibrillary tangles (NFTs), neuroinflammation, and blood-brain barrier (BBB) disruption. Proteomics has emerged as a pivotal technology in uncovering molecular mechanisms and identifying biomarkers for early diagnosis and intervention in AD. This paper reviews the genetic and molecular roles of APOE-ε4 in the pathology of AD, including its effects on Aβ aggregation, tau phosphorylation, neuroinflammation, and BBB integrity. Additionally, it highlights recent advances in serum proteomics, revealing APOE-ε4-dependent and independent protein signatures with potential as early biomarkers for AD. Despite technological progress, challenges such as population diversity, standardization, and distinguishing AD-specific biomarkers remain. Directions for future research emphasize multicenter longitudinal studies, multi-omics integration, and the clinical translation of proteomic findings to enable early detection of AD and personalized treatment strategies. Proteomics advances in AD research hold the promise of improving patient outcomes and reducing the global disease burden.

Sex Differences in Apolipoprotein E and Alzheimer Disease Pathology Across Ancestries

Importance

Age, sex, and apolipoprotein E (APOE) are the strongest risk factors for late-onset Alzheimer disease (AD). The role of APOE in AD varies with sex and ancestry. While the association of APOE with AD biomarkers also varies across sex and ancestry, no study has systematically investigated both sex-specific and ancestry differences of APOE on cerebrospinal fluid (CSF) biomarkers together, resulting in limited insights and generalizability.

Objective

To systematically investigate the association of sex and APOE-ε4 with 3 core CSF biomarkers across ancestries.

Design, Setting, and Participants

This cohort study examined 3 CSF biomarkers (amyloid β1-42 [Aβ42], phosphorylated tau 181 [p-tau], and total tau, in participants from 20 cohorts from July 1, 1985, to March 31, 2020. These individuals were grouped into African, Asian, and European ancestries based on genetic data. Data analyses were conducted from June 1, 2023, to November 10, 2024.

Exposure

Sex (male or female) and APOE-ε4.

Main Outcomes and Measures

The associations of sex and APOE-ε4 with biomarker levels were assessed within each ancestry group, adjusting for age. Meta-analyses were performed to identify these associations across ancestries. Sensitivity analyses were conducted to exclude the potential influence of the APOE-ε2 allele.

Results

This cohort study included 4592 individuals (mean [SD] age, 70.8 [10.2] years; 2425 [52.8%] female; 119 [2.6%] African, 52 [1.1%] Asian, and 4421 [96.3%] European). Higher APOE-ε4 dosage scores were associated with lower Aβ42 values (β [SE], -0.58 [0.02], P < .001), indicating more severe pathology; these associations were seen in men and women separately and jointly. The association with APOE-ε4 was statistically greater in men (β [SE], -0.63 [0.03]; P < .001) vs women (β [SE], -0.52 [0.03]; P < .001) of European ancestry (P = .01 for interaction). Women had higher levels of p-tau, indicating more severe neurofibrillary pathology. The association between APOE-ε4 dosage and p-tau was in the expected direction (higher APOE-ε4 dosage for higher p-tau values) in both sexes, but the difference between sexes was significant only in those of African ancestry (β [SE], 0.10 [0.18]; P = .57 for men; β [SE], 0.66 [0.17]; P < .001 for women; P = .03 for interaction). Women also had higher levels of total tau, indicating more neuronal damage. The association between APOE-ε4 dosage and total tau was stronger in women than in men in the African cohort (β [SE], 0.20 [0.22]; P = .36 for men and β [SE], 0.65 [0.22], P = .004 for women [P = .16 for interaction]) and European cohort (β [SE], 0.36 [0.03]; P < .001 in women and β [SE], 0.27 [0.03], P < .001 in men [P = .053 for interaction]); no significant associations were found in the Asian cohort. Sensitivity analysis excluding APOE-ε2 carriers yielded similar results.

Conclusions and Relevance

In this cohort study, the association of the APOE-ε4 risk allele with tau accumulation was higher in women than in men. These findings underscore the importance of considering sex differences in APOE-ε4's association with AD biomarkers and tau pathology mechanisms in AD. Although this study provides robust evidence of complex interplay between sex and APOE-ε4 for European ancestry, further research is needed to fully understand other ancestry differences.

Sex Differences in Longitudinal Tau-PET in Preclinical Alzheimer Disease: A Meta-Analysis

Importance

Alzheimer disease (AD) predominates in females at almost twice the rate relative to males. Mounting evidence in adults without AD indicates that females exhibit higher tau deposition than age-matched males, particularly in the setting of elevated β-amyloid (Aβ), but the evidence for sex differences in tau accumulation rates is inconclusive.

Objective

To examine whether female sex is associated with faster tau accumulation in the setting of high Aβ (as measured with positron emission tomography [PET]) and the moderating influence of sex on the association between APOEε4 carrier status and tau accumulation.

Data Sources

This meta-analysis used data from 6 longitudinal aging and AD studies, including the Alzheimer's Disease Neuroimaging Initiative, Berkeley Aging Cohort Study, BioFINDER 1, Harvard Aging Brain Study, Mayo Clinic Study of Aging, and Wisconsin Registry for Alzheimer Prevention. Longitudinal data were collected between November 2004 and May 2022.

Study Selection

Included studies required available longitudinal [18F]flortaucipir or [18F]-MK-6240 tau-PET scans, as well as baseline [11C] Pittsburgh Compound B, [18F]flutemetamol or [18F]florbetapir Aβ-PET scans. Recruitment criteria varied across studies. Analyses began on August 7, 2023, and were completed on February 5, 2024.

Data Extraction and Synthesis

In each study, primary analyses extracted estimates for the sex (female or male) and the sex by baseline Aβ-PET status (high or low) association with longitudinal tau-PET using a series of mixed-effects models. Secondary mixed-effects models extracted the interaction estimate for the association of sex by APOEε4 carrier status with longitudinal tau-PET. Study-specific estimates for each mixed-effects model were then pooled in a meta-analysis, and the global fixed effect (β) and total heterogeneity (I2) across studies were estimated. This study is reported following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline.

Main Outcomes and Measures

Seven tau-PET outcomes that showed cross-sectional sex differences were examined across temporal, parietal, and occipital lobes.

Results

Among 6 studies assessed, there were 1376 participants (761 [55%] female; mean [range] age at first tau scan, 71.9 [46-93] years; 401 participants [29%] with high baseline Aβ; 412 APOEε4 carriers [30%]). Among individuals with high baseline Aβ, female sex was associated with faster tau accumulation localized to inferior temporal (β = -0.14; 95% CI, -0.22 to -0.06; P = .009) temporal fusiform (β = -0.13; 95% CI, -0.23 to -0.04; P = .02), and lateral occipital regions (β = -0.15; 95% CI, -0.24 to -0.06; P = .009) compared with male sex. Among APOEε4 carriers, female sex was associated with faster inferior-temporal tau accumulation (β = -0.10; 95% CI, -0.16 to -0.03; P = .01).

Conclusions and Relevance

These findings suggest that sex differences in the pathological progression of AD call for sex-specific timing considerations when administrating anti-Aβ and anti-tau treatments.

A mini review of transforming dementia care in China with data-driven insights: overcoming diagnostic and time-delayed barriers

Introduction

Inadequate primary care infrastructure and training in China and misconceptions about aging lead to high mis-/under-diagnoses and serious time delays for dementia patients, imposing significant burdens on family members and medical carers.

Main body

A flowchart integrating rural and urban areas of China dementia care pathway is proposed, especially spotting the obstacles of mis/under-diagnoses and time delays that can be alleviated by data-driven computational strategies. Artificial intelligence (AI) and machine learning models built on dementia data are succinctly reviewed in terms of the roadmap of dementia care from home, community to hospital settings. Challenges and corresponding recommendations to clinical transformation are then reported from the viewpoint of diverse dementia data integrity and accessibility, as well as models' interpretability, reliability, and transparency.

Discussion

Dementia cohort study along with developing a center-crossed dementia data platform in China should be strongly encouraged, also data should be publicly accessible where appropriate. Only be doing so can the challenges be overcome and can AI-enabled dementia research be enhanced, leading to an optimized pathway of dementia care in China. Future policy-guided cooperation between researchers and multi-stakeholders are urgently called for dementia 4E (early-screening, early-assessment, early-diagnosis, and early-intervention).

Distinct medical and substance use histories associate with cognitive decline in Alzheimer's disease

INTRODUCTION

Phenotype clustering reduces patient heterogeneity and could be useful when designing precision clinical trials. We hypothesized that the onset of early cognitive decline in patients would exhibit variance predicated on the clinical history documented prior to an Alzheimer's disease (AD) diagnosis.

METHODS

Self-reported medical and substance use history (i.e., problem history) was used to cluster participants from the National Alzheimer's Coordinating Center (NACC) into distinct subtypes. Linear mixed effects modeling was used to determine the effect of problem history subtype on cognitive decline over 2 years.

RESULTS

Two thousand seven hundred fifty-four individuals were partitioned into three subtypes: minimal (n = 1380), substance use (n = 1038), and cardiovascular (n = 336). The cardiovascular problem history subtype had significantly worse cognitive decline over a 2 year follow-up period (p = 0.013).

DISCUSSION

Our study highlights the need to account for problem history to reduce heterogeneity of outcomes in AD clinical trials.

HIGHLIGHTS

Clinical data were used to identify subtypes of patients with Alzheimer's disease (AD) in the National Alzheimer's Coordinating Center dataset. Three problem history subtypes were found: minimal, substance use, and cardiovascular. The mean change in Clinical Dementia Rating Sum of Boxes (CDR-SB) was assessed over a 2 year follow-up. The cardiovascular subtype was associated with the worst cognitive decline. The magnitude of change in CDR-SB was similar to recent AD clinical trials.

A predictive model of cognitive impairment risk in older adults with hypertension

BACKGROUND

Hypertension is one of the most common diseases in the world, impacting global life expectancy and associated with an increased risk of cognitive impairment.

OBJECTIVE

This study aimed to develop a nomogram that accurately predicts the risk of cognitive impairment in hypertensive patients using the National Health and Nutrition Examination Study (NHANES).

METHODS

A total of 1517 hypertensive patients from NHANES 2011-2014 were included in this study. The population was divided into two groups: 1065 cases (70 %) in the train set and 452 cases (30 %) in the test set. Lasso regression model and multivariate logistic regression analyses identified predictors significantly associated with cognitive impairment, and the nomogram was constructed using these predictors. The performance of the model was assessed using metrics such as area under the curve (AUC) of receiver operating characteristic (ROC), calibration curves, and decision curve analysis (DCA).

RESULTS

The nomogram identified seven predictors, including sex, age, education, poverty income ratio (PIR), depression, vigorous work activity, and creatinine. A web-based dynamic nomogram (https://cognitive-impairment-in-hypertension.shinyapps.io/DynNomapp/) was constructed based on these factors. The AUC of the train set was 0.802 and the AUC of the test set was 0.756, indicating that the model had excellent discriminative ability. The calibration curve showed that the model was well-calibrated. The DCA indicated that early intervention for those at risk would result in a net benefit.

CONCLUSION

The model performed well and was clinically predictive, making it easy for clinicians to use and screen for possible cognitive impairment in elderly hypertensive patients.

Impact of APOE, Klotho, and sex on cognitive decline with aging

The effects of apolipoprotein E (APOE) and Klotho genes, both implicated in aging, on human cognition as a function of sex and age are yet to be definitively established. Here, we showed in the largest cohort studied to date (N = 320,861) that APOE homozygous ε4 carriers had a greater decline in cognition with aging compared to ε3 carriers (ε3/ε4 and ε3/ε3) as well as smaller hippocampi and amygdala (N = 29,510). Critically, sex and age differentially affected the decline in cognition. Younger (40 to 50 y) female homozygous ε4 carriers showed a cognitive advantage over female ε3 carriers, but this advantage was not present in males. By contrast, Klotho-VS heterozygosity did not affect cognition or brain volume, regardless of APOE genotype, sex, or age. These cognitive trajectories with aging demonstrate clear sex-dependent antagonistic pleiotropy effects of APOE ε4, but no effects of Klotho genotype on cognition and brain volume.

The Spectrum of Genetic Risk in Alzheimer Disease

Alzheimer disease (AD), the most common dementing syndrome in the United States, is currently established by the presence of amyloid-β and tau protein biomarkers in the setting of clinical cognitive impairment. These straightforward diagnostic parameters belie an immense complexity of genetic architecture underlying risk and presentation in AD. In this review, we provide a focused overview of the current state of AD genetics. We discuss the discovery of familial autosomal dominant genes, the identification of candidate genes associated with AD, and genetic variants conferring higher risk of developing AD compared with the general population. In particular, we discuss important features of AD risk due to the APOE ε4 allele. In addition to risk, we describe how the field has made headway understanding genetic factors that may protect from AD. The biological implications and practical limitations of information gleaned from genome-wide association studies in AD over the years are also discussed. The readers will have an up-to-date understanding of where we are in our efforts to understand the layers of genetic complexity in AD.

Gender differences in cognitive impairment among the elderly in rural West Texas counties

BACKGROUND

The prevalence of Alzheimer's disease or dementia in the elderly population has been increasing both nationally and globally. Males and females are impacted differently when it comes to cognitive health, and this can be influenced by various risk factors.

OBJECTIVE

This study highlights the sociodemographic, chronic disease, and genetic biomarker risk factors associated with gender differences and cognitive impairments in the elderly population living in Cochran, Parmer, and Bailey counties of rural West Texas.

METHODS

Cross tabulation, Pearson's chi-squared, two sample proportions, binary logistic regression, and multinomial logistic regression were utilized to analyze data. SPSS software was used to detect significant risk factors.

RESULTS

Using a bivariate logistic regression, the age group 70 and above of males and females for the Cochran and Parmer counties was found significantly associated with cognitive impairment. Anxiety, depression, diabetes, and cardiovascular disease were found to be significantly associated with an increased risk of cognitive impairment in females in Parmer County. Gender differences were observed in Cochran County for smoking but females in Bailey County were found to be more tobacco-dependent compared to other counties. However, in Cochran County the prevalence of cognitive impairment with rates of 66% for males and 70% for females was observed to be significantly lower in hypertensive group who consumed modified diet.

CONCLUSIONS

Gender-based disparities in cognitive impairment are essential for gaining more insights into Alzheimer's disease or dementia prevention and advancement of healthcare and medical approaches in the underserved rural communities of West Texas.

Latent profiles of modifiable dementia risk factors in later midlife: relationships with incident dementia, cognition, and neuroimaging outcomes

In 2020, the Lancet Commission identified 12 modifiable factors that increase population-level dementia risk. It is unclear if these risk factors co-occur among individuals in a clinically meaningful way. Using latent class analysis, we identified profiles of modifiable dementia risk factors in dementia-free adults aged 60-64 years from the UK Biobank. We then estimated associations between these profiles with incident dementia, cognition, and neuroimaging outcomes, and explored the differences across profiles in the effects of a polygenic risk score for Alzheimer's disease on outcomes. In 55,333 males and 63,063 females, three sex-specific latent profiles were identified: cardiometabolic risk, substance use-related risk, and low risk. The cardiometabolic risk profile in both males and females was associated with greater incidence of all-cause dementia (male: OR [95% CI] = 2.33 [2.03, 2.66]; female: OR [95% CI] = 1.44 [1.24, 1.68]), poorer cognitive performance, greater brain atrophy, and greater white matter hyperintensity volume compared to the low risk profile. The substance use-related risk profile in males was associated with poorer cognitive performance and greater white matter hyperintensities compared to the low risk profile, but no difference in all-cause dementia incidence was observed (OR [95% CI] = 1.00 [0.95, 1.06]). In females, the substance use-related risk profile demonstrated increased dementia incidence (OR [95% CI] = 1.58 [1.57, 1.58]) and greater brain atrophy but smaller white matter hyperintensity volume compared to the low risk profile. The polygenic risk score had larger effects among females, and differentially influenced outcomes across profiles; for instance, there were larger effects of the polygenic risk score on atrophy in the cardiometabolic profile vs. the low risk profile among males, and larger effects of the polygenic risk score on loss of white matter integrity in the cardiometabolic profile vs. the low risk profile among females. These results reveal three modifiable dementia risk profiles, their unique cognitive/neuroimaging outcomes, and their interactions with genetic risk for Alzheimer's disease. These differences highlight the need to consider population heterogeneity in risk prediction tools and in planning personalized prevention strategies.

Precision neurology

Over the past several decades, high-resolution brain imaging, blood and cerebrospinal fluid analyses, and other advanced technologies have changed diagnosis from an exercise depending primarily on the history and physical examination to a computer- and online resource-aided process that relies on larger and larger quantities of data. In addition, randomized controlled trials (RCT) at a population level have led to many new drugs and devices to treat neurological disease, including disease-modifying therapies. We are now at a crossroads. Combinatorially profound increases in data about individuals has led to an alternative to population-based RCTs. Genotyping and comprehensive "deep" phenotyping can sort individuals into smaller groups, enabling precise medical decisions at a personal level. In neurology, precision medicine that includes prediction, prevention and personalization requires that genomic and phenomic information further incorporate imaging and behavioral data. In this article, we review the genomic, phenomic, and computational aspects of precision medicine for neurology. After defining biological markers, we discuss some applications of these "-omic" and neuroimaging measures, and then outline the role of computation and ultimately brain simulation. We conclude the article with a discussion of the relation between precision medicine and value-based care.

Alzheimer's disease: insights into pathology, molecular mechanisms, and therapy

Alzheimer's disease (AD), the leading cause of dementia, is characterized by the accumulation of amyloid plaques and neurofibrillary tangles in the brain. This condition casts a significant shadow on global health due to its complex and multifactorial nature. In addition to genetic predispositions, the development of AD is influenced by a myriad of risk factors, including aging, systemic inflammation, chronic health conditions, lifestyle, and environmental exposures. Recent advancements in understanding the complex pathophysiology of AD are paving the way for enhanced diagnostic techniques, improved risk assessment, and potentially effective prevention strategies. These discoveries are crucial in the quest to unravel the complexities of AD, offering a beacon of hope for improved management and treatment options for the millions affected by this debilitating disease.

A Narrative Review: Relationship Between Glycemic Variability and Emerging Complications of Diabetes Mellitus

A growing body of evidence emphasizes the role of glycemic variability (GV) in the development of conventional diabetes-related complications. Furthermore, advancements in diabetes management and increased life expectancy have led to the emergence of new complications, such as cancer, liver disease, fractures, infections, and cognitive dysfunction. GV is considered to exacerbate oxidative stress and inflammation, acting as a major mechanism underlying these complications. However, few reviews have synthesized the association between GV and these emerging complications or examined their underlying mechanisms. Hence, this narrative review provides a comprehensive discussion of the burden, risks, and mechanisms of GV in these complications, offering further evidence supporting GV as a potential therapeutic target for diabetes management.

Quantifying natural amyloid plaque accumulation in the continuum of Alzheimer's disease using ADNI

Brain amyloid beta neuritic plaque accumulation is associated with an increased risk of progression to Alzheimer's disease (AD) [Pfeil, J., et al. in Neurobiol Aging 106: 119-129, 2021]. Several studies estimate rates of change in amyloid plaque over time in clinically heterogeneous cohorts with different factors impacting amyloid plaque accumulation from ADNI and AIBL [Laccarino, L., et al. in Annals Clin and Trans Neurol 6: 1113 1120, 2019, Vos, S.J., et al. in Brain 138: 1327-1338, 2015, Lim, Y.Y., et al. in Alzheimer's Dementia 9: 538-545, 2013], but there are no reports using non-linear mixed effect model for amyloid plaque progression over time similar to that existing of disease-modifying biomarkers for other diseases [Cook, S.F. and R.R. Bies in Current Pharmacol Rep 2: 221-230, 2016, Gueorguieva, I., et al. in Alzheimer's Dementia 19: 2253-2264, 2023]. This study describes the natural progression of amyloid accumulation with population mean and between-participant variability for baseline and intrinsic progression rates quantified across the AD spectrum. 1340 ADNI participants were followed over a 10-year period with 18F-florbetapir PET scans used for amyloid plaque detection. Non-linear mixed effect with stepwise covariate modelling (scm) was used. Change in natural amyloid plaque levels over 10 year period followed an exponential growth model with an intrinsic rate of approx. 3 centiloid units/year. Age, gender, APOE4 genotype and disease stage were important factors on the baseline in the natural amyloid model. In APOE4 homozygous carriers mean baseline amyloid was increased compared to APOE4 non carriers. These results demonstrate natural progression of amyloid plaque in the continuum of AD.

Epigenetic Mechanisms Underlying Sex Differences in Neurodegenerative Diseases

Neurodegenerative diseases are characterized by profound differences between females and males in terms of incidence, clinical presentation, and disease progression. Furthermore, there is evidence suggesting that differences in sensitivity to medical treatments may exist between the two sexes. Although the role of sex hormones and sex chromosomes in driving differential susceptibility to these diseases is well-established, the molecular alterations underlying these differences remain poorly understood. Epigenetic mechanisms, including DNA methylation, histone tail modifications, and the activity of non-coding RNAs, are strongly implicated in the pathogenesis of neurodegenerative diseases. While it is known that epigenetic mechanisms play a crucial role in sexual differentiation and that distinct epigenetic patterns characterize females and males, sex-specific epigenetic patterns have been largely overlooked in studies aiming to identify epigenetic alterations associated with neurodegenerative diseases. This review aims to provide an overview of sex differences in epigenetic mechanisms, the role of sex-specific epigenetic processes in the central nervous system, and the main evidence of sex-specific epigenetic alterations in three neurodegenerative diseases, including Alzheimer's disease, Parkinson's disease, and amyotrophic lateral sclerosis. Understanding the sex-related differences of these diseases is essential for developing personalized treatments and interventions that account for the unique epigenetic landscapes of each sex.

Targeting early tau pathology: probiotic diet enhances cognitive function and reduces inflammation in a preclinical Alzheimer's model

BACKGROUND

Alzheimer's disease (AD) remains incurable, yet its long prodromal phase offers a crucial window for early intervention. Pretangle tau, a precursor to neurofibrillary tangles, plays a key role in early AD pathogenesis. Intervening in pretangle tau pathology could significantly delay the progression of AD. The gut-brain axis, increasingly recognized as a contributor to AD, represents a promising therapeutic target due to its role in regulating neuroinflammation and neurodegeneration. While probiotics have shown cognitive benefits in amyloid-centered AD models, their effect on pretangle tau pathology remains elusive.

METHODS

This study evaluates the effects of probiotics in a rat model of preclinical AD, specifically targeting hyperphosphorylated pretangle tau in the locus coeruleus. TH-CRE rats (N = 47; 24 females and 23 males) received either AAV carrying pseudophosphorylated human tau (htauE14) or a control virus at 3 months of age. Probiotic or control diets were administered at 9-12 months, with blood and fecal samples collected for ELISA and 16S rRNA gene sequencing. Behavioral assessments were conducted at 13-14 months, followed by analysis of brain inflammation, blood-brain barrier integrity, and GSK-3β activation.

RESULTS

Rats expressing pseudophosphorylated tau displayed impairment in spatial Y-maze (F1,39 = 4.228, p = 0.046), spontaneous object location (F1,39 = 6.240, p = 0.017), and olfactory discrimination (F1,39 = 7.521, p = 0.009) tests. Phosphorylation of tau at S262 (t3 = -4.834) and S356 (t3 = -3.258) in the locus coeruleus was parallelled by GSK-3β activation in the hippocampus (F1,24 = 10.530, p = 0.003). Probiotic supplementation increased gut microbiome diversity (F1,31 = 8.065, p = 0.007) and improved bacterial composition (F1,31 = 3.4867, p = 0.001). The enhancement in gut microbiomes was associated with enhanced spatial learning (p < 0.05), reduced inflammation indexed by Iba-1 (F1,25 = 5.284, p = 0.030) and CD-68 (F1,26 = 8.441, p = 0.007) expression, and inhibited GSK-3β in female rats (p < 0.01 compared to control females).

CONCLUSIONS

This study underscores the potential of probiotics to modulate the gut-brain axis and mitigate pretangle tau-related pathology in preclinical AD. Probiotic supplementation could offer a novel early intervention strategy for AD, highlighting the pivotal role of gut health in neurodegeneration.

From Lab Bench to Hope: Emerging Gene Therapies in Clinical Trials for Alzheimer's Disease

Alzheimer's disease is a progressive neurodegenerative disorder that affects memory and cognitive abilities, affecting millions of people around the world. Current treatments focus on the management of symptoms, as no effective therapy has been approved to modify the underlying disease process. Gene therapy is a promising approach that can offer disease-modifying treatment for AD, targeting various aspects of the pathophysiology of the disease. This review presents a comprehensive overview of the current state of gene therapy research for AD, with a specific focus on clinical trials and preclinical studies that have used nerve growth factor (NGF), brain-derived neurotrophic factor (BDNF), apolipoprotein E2 (APOE2), and human telomerase reverse transcriptase (hTERT) as therapeutic gene therapy approaches. These gene targets have shown potential to alleviate the neuropathology of AD in animal studies and have demonstrated feasibility and safety in non-human primates. Despite the failure of the NGF gene therapy approach in clinical trials, we have reviewed and highlighted the reported findings and evaluations from the trials. Furthermore, the review included the conclusions of postmortem brain tissue analysis of AD patients who received NGF gene therapy. The goal is to learn from the failed trials and improve the approach in the future. Although gene therapy shows promise, it faces several challenges and limitations, including optimizing gene delivery methods, enhancing safety and efficacy profiles, and determining long-term results. This review contributes to the growing body of literature on innovative treatments for AD and highlights the need for more research and development to advance gene therapy as a viable treatment option for AD.

The effects of two Alzheimer's disease related genes APOE and MAPT in healthy young adults: An attentional blink study

BACKGROUND

Genetic risk factors start to affect the brain and behavior in Alzheimer's disease (AD) before clinical symptoms occur. Although AD is mainly associated with memory deficits, attention and executive dysfunctions can present at the early presymptomatic stages in middle age for those with non-modifiable risks.

OBJECTIVE

Here, we investigated whether known risk genes for AD already affected attention in young adulthood.

METHODS

A total of 392 healthy young adults aged around 20 years underwent genetic testing for risks of dementia (APOE and MAPT) and performed a computerized cognitive test for temporal attention called the Attentional Blink (AB) task, in which patients with dementia tested in previous studies often showed reduced performance. Here, the AB task was analyzed using repeated-measurements analysis of variance for the ability of visual perception, attention deployment and temporal memory encoding/binding performance.

RESULTS

The results showed that all participants exhibited AB effects. Importantly, genetic risk factors had statistically significant influence on temporal attention depending on sex in healthy young adults. APOE4 status was associated with enhanced attention deployment in males but not females, while MAPT AA carriers had poorer performance in AB but only in females. No genetic effects were found for visual perception and temporal memory binding errors between high and low risk groups.

CONCLUSIONS

We provided evidence that both APOE and MAPT start to affect attentional function as early as young adulthood. Furthermore, unlike previous findings in older people, these genes had a differential effect for males and females in young adults.

Biological Sex Disparities in Alzheimer's Disease

Alzheimer's disease is a highly complex and multifactorial neurodegenerative disorder, with age being the most significant risk factor. The incidence of Alzheimer's disease doubles every 5 years after the age of 65. Consequently, one of the major challenges in Alzheimer's disease research is understanding how the brain changes with age. Gaining insights into these changes could help identify individuals who are more prone to developing Alzheimer's disease as they age. Over the past 25 years, studies on brain aging have examined thousands of human brains to explore the neuronal basis of age-related cognitive decline. However, most of these studies have focused on adults over 60, often neglecting the critical menopause transition period. During menopause, women experience a substantial decline in ovarian sex hormone production, with a decrease of about 90% in estrogen levels. Estrogen is known for its neuroprotective effects, and its significant loss during menopause affects various biological systems, including the brain. Importantly, despite known differences in dementia risk between sexes, the impact of biological sex and sex hormones on brain aging and the development of Alzheimer's disease remains underexplored.

Histopathological changes of nervous tissue in women over 60 years of age with Alzheimer's disease and their relationship with menopause

INTRODUCTION

Ageing is a natural and irreversible process that primarily manifests in older age, becoming more common after the age of 60. Currently, a significant increase has been observed in the elderly population, with forecasts indicating that this group will triple in size over the next 50 years. This phenomenon is evident in several countries, including Japan, Mexico, Brazil, and Colombia, where the growing population of older adults is accompanied by an increased risk of neurodegenerative diseases, such as Alzheimer's disease. Studies have shown differences in the onset and progression of the disease between men and women, highlighting menopause and hormonal factors as key determinants in women. An association has been identified between a lower exposure to endogenous oestrogens and a higher risk of dementia in women, linked to the action of the enzyme β-secretase (BACE1), which is involved in the formation of amyloid aggregates associated with Alzheimer's disease. These findings highlight the importance of thoroughly investigating and understanding the impact of ageing and related diseases on the current and future population.

OBJECTIVE

This study aims to describe the histopathological changes in nervous tissue in women over 60 years of age with Alzheimer's disease and their relationship to menopause.

METHODOLOGY

A comprehensive search was conducted in databases such as PubMed, ScienceDirect, Frontiers, Scopus, and Springer.

RESULTS

Two hundred thirteen articles were selected for review and 45 full articles were chosen.

CONCLUSIONS

Alzheimer's disease is characterised by a progressive loss of cognitive function due to brain lesions, including the accumulation of amyloid-beta plaques and neuronal apoptosis. Hormonal changes during menopause may contribute to the onset of the disease.

Sex and APOE ε4 allele differences in longitudinal white matter microstructure in multiple cohorts of aging and Alzheimer's disease

INTRODUCTION

The effects of sex and apolipoprotein E (APOE)-Alzheimer's disease (AD) risk factors-on white matter microstructure are not well characterized.

METHODS

Diffusion magnetic resonance imaging data from nine well-established longitudinal cohorts of aging were free water (FW)-corrected and harmonized. This dataset included 4741 participants (age = 73.06 ± 9.75) with 9671 imaging sessions over time. FW and FW-corrected fractional anisotropy (FAFWcorr) were used to assess differences in white matter microstructure by sex and APOE ε4 carrier status.

RESULTS

Sex differences in FAFWcorr in projection tracts and APOE ε4 differences in FW limbic and occipital transcallosal tracts were most pronounced.

DISCUSSION

There are prominent differences in white matter microstructure by sex and APOE ε4 carrier status. This work adds to our understanding of disparities in AD. Additional work to understand the etiology of these differences is warranted.

HIGHLIGHTS

Sex and apolipoprotein E (APOE) ε4 carrier status relate to white matter microstructural integrity. Females generally have lower free water-corrected fractional anisotropy compared to males. APOE ε4 carriers tended to have higher free water than non-carriers.

Sex differences in the relationships between 24-h rest-activity patterns and plasma markers of Alzheimer's disease pathology

BACKGROUND

Although separate lines of research indicated a moderating role of sex in both sleep-wake disruption and in the interindividual vulnerability to Alzheimer's disease (AD)-related processes, the quantification of sex differences in the interplay between sleep-wake dysregulation and AD pathology remains critically overlooked. Here, we examined sex-specific associations between circadian rest-activity patterns and AD-related pathophysiological processes across the adult lifespan.

METHODS

Ninety-two cognitively unimpaired adults (mean age = 59.85 ± 13.77 years, range = 30-85, 47 females) underwent 10 days of actigraphic recordings, and blood drawing. Standard non-parametric indices of 24-h rest-activity rhythm fragmentation (intradaily variability, IV) and stability (interdaily stability, IS) were extracted from actigraphy data using the GGIR package. Plasma concentrations of neurofilament light chain (NfL), glial fibrillary acidic protein (GFAP), amyloid-β42/40 (Aβ42/40), total tau, and tau phosphorylated at threonine 181 (p-tau181) or threonine 231 (p-tau231) were measured using Single molecule array technology. Multiple linear regression models were adjusted for age, sex, education, body mass index, and actigraphic recording duration.

RESULTS

Higher IV, indicating worse 24-h rest-activity rhythm fragmentation, was associated with elevated levels of plasma NfL (t(85) = 4.26, P < 0.0001), GFAP (t(85) = 2.49, P = 0.01), and at trend level with lower Aβ42/40 ratio values (t(85) = -1.95, P = 0.054). Lower IS, reflecting less day-to-day stability in the 24-h rest-activity rhythm, was linked to elevated levels of plasma NfL (t(85) = -2.24, P = 0.03), but not with the other plasma biomarkers. Importantly, interaction models demonstrated that male participants were driving the observed relationships between IV and plasma NfL (t(84) = 4.05, P < 0.001) or GFAP (t(84) = 3.60, P < 0.001), but also revealed a male vulnerability in models testing interactions with p-tau181 (IV: t(76) = 3.71, P < 0.001; IS: t(76) = -3.30, P = 0.001) and p-tau231 (IV: t(82) = 3.28, P = 0.002). Sensitivity analyses further showed that accounting for potential confounding factors such as APOE genotype, depression, and self-reported symptoms of possible sleep apnea did not modify the observed relationships.

CONCLUSIONS

These findings suggest that the association between disrupted circadian rest-activity patterns and AD pathophysiological processes may be more evident in cognitively unimpaired males. Our results contribute to the precision medicine approach, and they have clinical implications for improved early detection and selection of at-risk individuals to be enrolled in preventive interventions.

Global burden of Alzheimer's disease and other dementias attributed to metabolic risks from 1990 to 2021: results from the global burden of disease study 2021

OBJECTIVE

The risk of Alzheimer's disease (AD) and other dementias increases with greater global exposure to metabolic risks, making this a crucial public health issue. This study aimed to report the metabolism-attributable global burden of AD and other dementias from 1990 to 2021.

METHODS

The Global Burden of Disease Study (GBD) 2021 collected data on the number of deaths and disability-adjusted life-years (DALYs) related to AD and other dementias caused by metabolic risks, including high fasting plasma glucose (FPG) and high body mass index (BMI). The analysis assessed the disease burden and temporal patterns worldwide, examining data by region, country, level of social development, age group, and sex.

RESULTS

Globally, the count of AD and other dementia-related deaths due to metabolic risks grew from 98,608 to 399,824, a 4.1-fold increase. For dementias related to high FPG and high BMI, the age-standardized mortality rates (ASMR) and age-standardized DALY rate (ASDR) increased with age and were higher in females than in males. In 2021, the highest burden was observed in high-income North America. The ASMR and ASDR have grown worldwide between 1990 and 2021. The burden of metabolism-related AD and other dementias was positively correlated with the Socio-Demographic Index (SDI), with higher ASMR and ASDR in high SDI regions but showing more pronounced increases in low and low-middle SDI regions.

CONCLUSIONS

Metabolism-related global burden of AD and other dementias is increasing, particularly among women and in high-income regions. Targeted prevention programs for dementia should be developed, along with early interventions for risk factors.

The Landscape of Sex- and APOE Genotype-Specific Transcriptional Changes in Alzheimer's Disease at the Single Cell Level

Alzheimer's disease (AD) is the most common form of dementia, with approximately two-thirds of AD patients are females. Basic and clinical research studies show evidence supporting sex-specific differences contributing to the complexity of AD. There is also strong evidence supporting sex-specific interaction between the primary genetic risk factor of AD, APOE4 and AD-associated neurodegenerative processes. Recent studies by us and others have identified sex and/or APOE4 specific differentially expressed genes in AD based on the bulk tissue RNA-sequencing data of postmortem human brain samples in AD. However, there lacks a comprehensive investigation of the interplay between sex and APOE genotypes at the single cell level. In the current study, we systematically explore sex and APOE genotype differences in single cell transcriptomics in AD. Our work provides a comprehensive overview of sex and APOE genotype-specific transcriptomic changes across 54 high-resolution cell types in AD and highlights individual genes and brain cell types that show significant differences between sexes and APOE genotypes. This study lays the groundwork for exploring the complex molecular mechanisms of AD and will inform the development of effective sex- and APOE-stratified interventions for AD.

Sex differences in interacting genetic and functional connectivity biomarkers in Alzheimer's disease

As of 2023, it is estimated that 6.7 million individuals in the United States live with Alzheimer's disease (AD). Prior research indicates that AD disproportionality affects females; females have a greater incidence rate, perform worse on a variety of neuropsychological tasks, and have greater total brain atrophy. Recent research shows that hippocampal functional connectivity differs by sex and may be related to the observed sex differences in AD, and apolipoprotein E (ApoE) ε4 carriers have reduced hippocampal functional connectivity. The purpose of this study was to determine if the ApoE genotype plays a role in the observed sex differences in hippocampal functional connectivity in Alzheimer's disease. The resting state fMRI and T2 MRI of individuals with AD (n = 30, female = 15) and cognitively normal individuals (n = 30, female = 15) from the Alzheimer's Disease Neuroimaging Initiative (ADNI) were analyzed using the functional connectivity toolbox (CONN). Our results demonstrated intrahippocampal functional connectivity differed between those without an ε4 allele and those with at least one ε4 allele in each group. Additionally, intrahippocampal functional connectivity differed only by sex when Alzheimer's participants had at least one ε4 allele. These results improve our current understanding of the role of the interacting relationship between sex, ApoE genotype, and hippocampal function in AD. Understanding these biomarkers may aid in the development of sex-specific interventions for improved AD treatment.

Menopause and Alzheimer's disease susceptibility: Exploring the potential mechanisms

Alzheimer's Disease (AD), responsible for 62% of all dementia cases, is a progressive neurodegenerative condition that leads to cognitive dysfunction. The prevalence of AD is consistently higher in women suggesting they are disproportionately affected by this disease. Despite this, our understanding of this female AD vulnerability remains limited. Menopause has been identified as a potential contributing factor to AD in women, with earlier menopause onset associated with greater AD risk. However, the underlying mechanisms responsible for this increased risk are not fully understood. This review examines the potential role of menopause in the development of Alzheimer's Disease providing a mechanistic overview of the available literature from hormones to pathology. While literature is now emerging that indicates a role of hormonal shifts, gut dysbiosis, lipid dysregulation and inflammation, more research is needed to fully elucidate the mechanisms involved.

Distinct medical and substance use histories associate with cognitive decline in Alzheimer's Disease

INTRODUCTION

Phenotype clustering reduces patient heterogeneity and could be useful when designing precision clinical trials. We hypothesized that the onset of early cognitive decline in patients would exhibit variance predicated on the clinical history documented prior to an Alzheimer's Disease (AD) diagnosis.

METHODS

Self-reported medical and substance use history (i.e., problem history) was used to cluster participants from the National Alzheimer's Coordinating Centers (NACC) into distinct subtypes. Linear mixed effects modeling was used to determine the effect of problem history subtype on cognitive decline over two years.

RESULTS

2754 individuals were partitioned into three subtypes: minimal (n = 1380), substance use (n = 1038), and cardiovascular (n = 336) subtypes. The cardiovascular problem history subtype had significantly worse cognitive decline over a two-year follow-up period (p = 0.013).

DISCUSSION

Our study highlights the need to account for problem history to reduce heterogeneity of outcomes in AD clinical trials.

APOE4 and Chronic Health Risk Factors are Associated with Sex-Specific Preclinical Alzheimer's Disease Neuroimaging Biomarkers

Introduction

Two thirds of Alzheimer's disease (AD) patients are female. Genetic and chronic health risk factors for AD affect females more negatively compared to males.

Objective

This exploratory multimodal neuroimaging study aimed to examine sex differences in cognitively unimpaired older adults on: (1) amyloid-β via 18F-AV-45 Florbetapir PET imaging, (2) neurodegeneration via T1 weighted MRI volumetrics, (3) cerebral blood flow via ASL-MRI. We identified AD risk factors including genetic (APOE genotype status) and health markers (fasting glucose, mean arterial pressure, waist-to-hip ratio, and android and gynoid body fat) associated with neuroimaging outcomes for which we observed sex differences.

Methods

Participants were sedentary, amyloid-β positive older adults (N = 112, ages 65-87 years) without evidence of cognitive impairment (CDR = 0).

Results

Multivariate analysis of covariance models adjusted for intracranial volume, age, and years of education demonstrated lower volume (F (7, 102) = 2.67, p = 0.014) and higher blood flow F (6, 102) = 4.25, p =<0.001) among females compared to males in regions of interest connected to AD pathology and the estrogen receptor network. We did not observe sex differences in amyloid-β levels. Higher than optimal waist to hip ratio was most strongly associated with lower volume, while higher android fat percentage and APOE ε4 carrier status were most strongly associated with higher blood flow among female participants.

Discussion

Findings suggest genetic and chronic health risk factors are associated with sex-specific AD neuroimaging biomarkers. Underlying sex-specific biological pathways may explain these findings. Our results highlight the importance of considering sex differences in neuroimaging studies and when developing effective interventions for AD prevention and risk reduction.

Skeletal muscle proteome differs between young APOE3 and APOE4 targeted replacement mice in a sex-dependent manner

Introduction

Apolipoprotein E4 (APOE4) is the strongest genetic risk factor for Alzheimer's disease (AD), yet it's unclear how this allele mediates risk. APOE4 carriers experience reduced mobility and faster decline in muscle strength, suggesting skeletal muscle involvement. Mitochondria are critical for muscle function and although we have reported defects in muscle mitochondrial respiration during early cognitive decline, APOE4-mediated effects on muscle mitochondria are unknown.

Methods

Here, we sought to determine the impact of APOE4 on skeletal muscle bioenergetics using young, male and female APOE3 (control) and APOE4 targeted replacement mice (n = 8 per genotype/sex combination). We examined the proteome, mitochondrial respiration, fiber size, and fiber-type distribution in skeletal muscle.

Results

We found that APOE4 alters mitochondrial pathway expression in young mouse muscle in a sex-dependent manner without affecting respiration and fiber size or composition relative to APOE3. In both sexes, the expression of mitochondrial pathways involved in electron transport, ATP synthesis, and heat production by uncoupling proteins and mitochondrial dysfunction significantly differed between APOE4 and APOE3 muscle. For pathways with predicted direction of activation, electron transport and oxidative phosphorylation were upregulated while mitochondrial dysfunction and sirtuin signaling were downregulated in female APOE4 vs. APOE3 muscle. In males, sulfur amino acid metabolism was upregulated in APOE4 vs. APOE3 muscle.

Discussion

This work highlights early involvement of skeletal muscle in a mouse model of APOE4-linked AD, which may contribute to AD pathogenesis or serve as a biomarker for brain health.

Associations between sex and lifestyle activities with cognitive reserve in mid-life adults with genetic risk for Alzheimer's disease

BACKGROUND

Females have a higher age-adjusted incidence of Alzheimer's Disease (AD) than males, even when accounting for longer lifespan and, therefore, stand to benefit the most from dementia prevention efforts. As exposure to many modifiable risk factors for dementia begins in mid-life, interventions must be implemented from middle-age. Building cognitive reserve, particularly through stimulating avocational activities and occupational attainment presents a crucial, underexplored, dementia prevention approach for mid-life. It is currently unknown, however, whether modifiable lifestyle factors can protect against AD processes, from mid-life, differentially for females and males who carry inherited risk for late-life dementia. To address this gap, this study investigated the impact of biological sex and APOE4 carrier status on the relationship between stimulating activities, occupational attainment, and cognition in mid-life.

METHODS

We leveraged the PREVENT-Dementia program, the world's largest study investigating the origins and early diagnosis of dementia in mid-life at-risk individuals (N = 700; 40-59 years). Cognitive performance was measured using the Cognito Battery and the Visual Short Term Memory Binding task. Mid-life specific reserve contributors were assessed via the Lifetime of Experiences Questionnaire.

RESULTS

Females had significantly better episodic and relational memory (p < 0.001), and lower occupational attainment than males (p < 0.001). Engagement in stimulating activities was positively associated with episodic and relational memory, regardless of sex and APOE4 status (β = 0.05, CI 0.03-0.07, p < 0.001). APOE4 carriers showed significant sex differences in the association between occupational attainment and episodic and relational memory (β = 0.38, CI 0.12-0.63, p = 0.003). APOE4 carrier females with higher occupational attainment showed better cognition (β = 0.16, CI -0.002-0.32, p = 0.053), whereas APOE4 carrier males showed the opposite effect (β = -0.20, CI -0.40 - -0.001, p = 0.049).

CONCLUSION

Our findings suggest that occupational attainment in mid-life contributes to cognitive reserve against inherited risk of dementia in females, but not males. They highlight the need for high precision approaches that consider biological sex and APOE4 carrier status to inform Alzheimer's disease prevention strategies and clinical trials.

APOE4 rat model of Alzheimer's disease: sex differences, genetic risk and diet

The strongest genetic risk factor for Alzheimer's disease (AD) is the ε4 allele of apolipoprotein E (ApoE ε4). A high fat diet also adds to the risk of dementia and AD. In addition, there are sex differences as women carriers have a higher risk of an earlier onset and rapid decline in memory than men. The present study looked at the effect of the genetic risk of ApoE ε4 together with a high fat/high sucrose diet (HFD/HSD) on brain function in male and female rats using magnetic resonance imaging. We hypothesized female carriers would present with deficits in cognitive behavior together with changes in functional connectivity as compared to male carriers. Four-month-old wildtype and human ApoE ε4 knock-in (TGRA8960), male and female Sprague Dawley rats were put on a HFD/HSD for four months. Afterwards they were imaged for changes in function using resting state BOLD functional connectivity. Images were registered to, and analyzed, using a 3D MRI rat atlas providing site-specific data on 173 different brain areas. Resting state functional connectivity showed male wildtype had greater connectivity between areas involved in feeding and metabolism while there were no differences between female and male carriers and wildtype females. The data were unexpected. The genetic risk was overshadowed by the diet. Male wildtype rats were most sensitive to the HFD/HSD presenting with a deficit in cognitive performance with enhanced functional connectivity in neural circuitry associated with food consumption and metabolism.

AI for the prediction of early stages of Alzheimer's disease from neuroimaging biomarkers - A narrative review of a growing field

OBJECTIVES

The objectives of this narrative review are to summarize the current state of AI applications in neuroimaging for early Alzheimer's disease (AD) prediction and to highlight the potential of AI techniques in improving early AD diagnosis, prognosis, and management.

METHODS

We conducted a narrative review of studies using AI techniques applied to neuroimaging data for early AD prediction. We examined single-modality studies using structural MRI and PET imaging, as well as multi-modality studies integrating multiple neuroimaging techniques and biomarkers. Furthermore, they reviewed longitudinal studies that model AD progression and identify individuals at risk of rapid decline.

RESULTS

Single-modality studies using structural MRI and PET imaging have demonstrated high accuracy in classifying AD and predicting progression from mild cognitive impairment (MCI) to AD. Multi-modality studies, integrating multiple neuroimaging techniques and biomarkers, have shown improved performance and robustness compared to single-modality approaches. Longitudinal studies have highlighted the value of AI in modeling AD progression and identifying individuals at risk of rapid decline. However, challenges remain in data standardization, model interpretability, generalizability, clinical integration, and ethical considerations.

CONCLUSION

AI techniques applied to neuroimaging data have the potential to improve early AD diagnosis, prognosis, and management. Addressing challenges related to data standardization, model interpretability, generalizability, clinical integration, and ethical considerations is crucial for realizing the full potential of AI in AD research and clinical practice. Collaborative efforts among researchers, clinicians, and regulatory agencies are needed to develop reliable, robust, and ethical AI tools that can benefit AD patients and society.

Microglia signaling in health and disease - Implications in sex-specific brain development and plasticity

Microglia, the intrinsic neuroimmune cells residing in the central nervous system (CNS), exert a pivotal influence on brain development, homeostasis, and functionality, encompassing critical roles during both aging and pathological states. Recent advancements in comprehending brain plasticity and functions have spotlighted conspicuous variances between male and female brains, notably in neurogenesis, neuronal myelination, axon fasciculation, and synaptogenesis. Nevertheless, the precise impact of microglia on sex-specific brain cell plasticity, sculpting diverse neural network architectures and circuits, remains largely unexplored. This article seeks to unravel the present understanding of microglial involvement in brain development, plasticity, and function, with a specific emphasis on microglial signaling in brain sex polymorphism. Commencing with an overview of microglia in the CNS and their associated signaling cascades, we subsequently probe recent revelations regarding molecular signaling by microglia in sex-dependent brain developmental plasticity, functions, and diseases. Notably, C-X3-C motif chemokine receptor 1 (CX3CR1), triggering receptors expressed on myeloid cells 2 (TREM2), calcium (Ca2+), and apolipoprotein E (APOE) emerge as molecular candidates significantly contributing to sex-dependent brain development and plasticity. In conclusion, we address burgeoning inquiries surrounding microglia's pivotal role in the functional diversity of developing and aging brains, contemplating their potential implications for gender-tailored therapeutic strategies in neurodegenerative diseases.

APOE4-related differences in cortical thickness are modulated by sex in middle age

Apolipoprotein E (APOE) ε4, the strongest genetic risk for late-onset Alzheimer's disease (AD), confers greater risk in females than males. While APOE4-related modulation of structural brain integrity in AD is well documented, extant literature on sex-APOE interactions has focused on older adults. The understanding of the healthy brain as a part of the normal aging process and as distinct from explicit disease or pathology is essential before comparison can be made with pathological states. Hence, it is crucial to characterize and better understand these relationships in middle-age prior to the onset of overt clinical symptoms and advanced neurodegeneration. The present study examined the relationships between sex, APOE status, and cortical thickness in 128 healthy, cognitively unimpaired, middle-aged adults (ages 40-60, M(SD) = 49.97(6.04); 77 females). All participants underwent structural magnetic resonance imaging and were genotyped for APOE (APOE4 +  = 38; APOE4- = 90). Compared to males, females had thicker superior frontal cortices bilaterally, left middle temporal cortex, and left pars triangularis. APOE4 + had thinner left rostral middle frontal gyrus compared to APOE4-. Female compared to male APOE4- had thicker left banks of the superior temporal sulcus, left caudal anterior cingulate, left superior frontal, left superior parietal, and right precentral cortices. Female compared to male APOE4 + had thicker superior frontal cortices bilaterally. Female APOE4 + had thinner left rostral anterior cingulate cortex compared to female APOE4-. Overall, APOE-related differences in cortical thickness are more pronounced in females and detectable in middle age, well before the onset of overt clinical symptoms of AD.

Phenome-Wide Association of APOE Alleles in the All of Us Research Program

Background

Genetic variation in APOE is associated with altered lipid metabolism, as well as cardiovascular and neurodegenerative disease risk. However, prior studies are largely limited to European ancestry populations and differential risk by sex and ancestry has not been widely evaluated. We utilized a phenome-wide association study (PheWAS) approach to explore APOE-associated phenotypes in the All of Us Research Program.

Methods

We determined APOE alleles for 181,880 All of Us participants with whole genome sequencing and electronic health record (EHR) data, representing seven gnomAD ancestry groups. We tested association of APOE variants, ordered based on Alzheimer's disease risk hierarchy (ε2/ε2<ε2/ε3<ε3/ε3<ε2/ε4<ε3/ε4<ε4/ε4), with 2,318 EHR-derived phenotypes. Bonferroni-adjusted analyses were performed overall, by ancestry, by sex, and with adjustment for social determinants of health (SDOH).

Findings

In the overall cohort, PheWAS identified 17 significant associations, including an increased odds of hyperlipidemia (OR 1.15 [1.14-1.16] per APOE genotype group; P=1.8×10-129), dementia, and Alzheimer's disease (OR 1.55 [1.40-1.70]; P=5×10-19), and a reduced odds of fatty liver disease (OR 0.93 [0.90-0.95]; P=1.6×10-9) and chronic liver disease. ORs were similar after SDOH adjustment and by sex, except for an increased number of cardiovascular associations in males, and decreased odds of noninflammatory disorders of vulva and perineum in females (OR 0.89 [0.84-0.94]; P=1.1×10-5). Significant heterogeneity was observed for hyperlipidemia and mild cognitive impairment across ancestry. Unique associations by ancestry included transient retinal arterial occlusion in the European ancestry group, and first-degree atrioventricular block in the American Admixed/Latino ancestry group.

Interpretation

We replicate extensive phenotypic associations with APOE alleles in a large, diverse cohort, despite limitations in accuracy for EHR-derived phenotypes. We provide a comprehensive catalog of APOE-associated phenotypes and present evidence of unique phenotypic associations by sex and ancestry, as well as heterogeneity in effect size across ancestry.

Updates in Alzheimer's disease: from basic research to diagnosis and therapies

Alzheimer's disease (AD) is the most common neurodegenerative disorder, characterized pathologically by extracellular deposition of β-amyloid (Aβ) into senile plaques and intracellular accumulation of hyperphosphorylated tau (pTau) as neurofibrillary tangles. Clinically, AD patients show memory deterioration with varying cognitive dysfunctions. The exact molecular mechanisms underlying AD are still not fully understood, and there are no efficient drugs to stop or reverse the disease progression. In this review, we first provide an update on how the risk factors, including APOE variants, infections and inflammation, contribute to AD; how Aβ and tau become abnormally accumulated and how this accumulation plays a role in AD neurodegeneration. Then we summarize the commonly used experimental models, diagnostic and prediction strategies, and advances in periphery biomarkers from high-risk populations for AD. Finally, we introduce current status of development of disease-modifying drugs, including the newly officially approved Aβ vaccines, as well as novel and promising strategies to target the abnormal pTau. Together, this paper was aimed to update AD research progress from fundamental mechanisms to the clinical diagnosis and therapies.

Texture-based morphometry in relation to apolipoprotein ε4 genotype, ageing and sex in a midlife population

Brain atrophy and cortical thinning are typically observed in people with Alzheimer's disease (AD) and, to a lesser extent, in those with mild cognitive impairment. In asymptomatic middle-aged apolipoprotein ε4 (ΑPOE4) carriers, who are at higher risk of future AD, study reports are discordant with limited evidence of brain structural differences between carriers and non-carriers of the ε4 allele. Alternative imaging markers with higher sensitivity at the presymptomatic stage, ideally quantified using typically acquired structural MRI scans, would thus be of great benefit for the detection of early disease, disease monitoring and subject stratification. In the present cross-sectional study, we investigated textural properties of T1-weighted 3T MRI scans in relation to APOE4 genotype, age and sex. We pooled together data from the PREVENT-Dementia and ALFA studies focused on midlife healthy populations with dementia risk factors (analysable cohort: 1585 participants; mean age 56.2 ± 7.4 years). Voxel-based and texture (examined features: contrast, entropy, energy, homogeneity) based morphometry was used to identify areas of volumetric and textural differences between APOE4 carriers and non-carriers. Textural maps were generated and were subsequently harmonised using voxel-wise COMBAT. For all analyses, APOE4, sex, age and years of education were used as model predictors. Interactions between APOE4 and age were further examined. There were no group differences in regional brain volume or texture based on APOE4 carriership or when age × APOE4 interactions were examined. Older people tended to have a less homogeneous textural profile in grey and white matter and a more homogeneous profile in the ventricles. A more heterogeneous textural profile was observed for females in areas such as the ventricles, frontal and parietal lobes and for males in the brainstem, cerebellum, precuneus and cingulate. Overall, we have shown the absence of volumetric and textural differences between APOE4 carriers and non-carriers at midlife and have established associations of textural features with ageing and sex.

Exploring the parity paradox: Differential effects on neuroplasticity and inflammation by APOEe4 genotype at middle age

Female sex and Apolipoprotein E (APOE) ε4 genotype are top non-modifiable risk factors for Alzheimer's disease (AD). Although female-unique experiences like parity (pregnancy and motherhood) have positive effects on neuroplasticity at middle age, previous pregnancy may also contribute to AD risk. To explore these seemingly paradoxical long-term effects of parity, we investigated the impact of parity with APOEε4 genotype by examining behavioural and neural biomarkers of brain health in middle-aged female rats. Our findings show that primiparous (parous one time) hAPOEε4 rats display increased use of a non-spatial cognitive strategy and exhibit decreased number and recruitment of new-born neurons in the ventral dentate gyrus of the hippocampus in response to spatial working memory retrieval. Furthermore, primiparity and hAPOEε4 genotype synergistically modulate inflammatory markers in the ventral hippocampus. Collectively, these findings demonstrate that previous parity in hAPOEε4 rats confers an added risk to present with reduced activity and engagement of the hippocampus as well as elevated pro-inflammatory signaling, and underscore the importance of considering female-specific factors and genotype in health research.

Linking alcohol use to Alzheimer's disease: Interactions with aging and APOE along immune pathways

Although it is known that APOE genotype is the strongest genetic risk factor for late-onset Alzheimer's disease, development is a multifactorial process. Alcohol use is a contributor to the epidemic of Alzheimer's disease and related dementias in the US and globally, yet mechanisms are not fully understood. Carriers of the APOE ε4 allele show elevated risk of dementia in relation to several lifestyle factors, including alcohol use. In this review, we describe how alcohol interacts with APOE genotype and aging with potential implications for Alzheimer's disease promotion. Age-related immune senescence and "inflammaging" (i.e., low-grade inflammation associated with aging) are increasingly recognized as contributors to age-related disease. We focus on three immune pathways that are likely contributors to Alzheimer's disease development, centering on alcohol and APOE genotype interactions, specifically: 1) microbial translocation and immune activation, 2) the senescence associated secretory phenotype, and 3) neuroinflammation. First, microbial translocation, the unphysiological movement of gut products into systemic circulation, elicits a proinflammatory response and increases with aging, with proposed links to Alzheimer's disease. Second, the senescence associated secretory phenotype is a set of intercellular signaling factors, e.g., proinflammatory cytokines and chemokines, growth regulators, and proteases, that drives cellular aging when senescent cells remain metabolically active. The senescence associated secretory phenotype can drive development of aging-diseases such as Alzheimer's disease. Third, neuroinflammation occurs via numerous mechanisms such as microglial activation and is gaining recognition as an etiological factor in the development of Alzheimer's disease. This review focuses on interactions of alcohol with APOE genotype and aging along these three pathways that may promote Alzheimer's disease. Further research on these processes may inform development of strategies to prevent onset and progression of Alzheimer's disease and to delay associated cognitive decline.

Prevalence and clinicopathological features of primary age-related tauopathy (PART): A large forensic autopsy study

INTRODUCTION

Primary age-related tauopathy (PART), often regarded as a minimally symptomatic pathology of old age, lacks comprehensive cohorts across various age groups.

METHODS

We examined PART prevalence and clinicopathologic features in 1589 forensic autopsy cases (≥40 years old, mean age ± SD 70.2 ± 14.2 years).

RESULTS

PART cases meeting criteria for argyrophilic grain diseases (AGD) were AGD+PART (n = 181). The remaining PART cases (n = 719, 45.2%) were classified as comorbid conditions (PART-C, n = 90) or no comorbid conditions (pure PART, n = 629). Compared to controls (n = 208), Alzheimer's disease (n = 133), and AGD+PART, PART prevalence peaked in the individuals in their 60s (65.5%) and declined in the 80s (21.5%). No significant clinical background differences were found (excluding controls). However, PART-C in patients inclusive of age 80 had a higher suicide rate than pure PART (p < 0.05), and AGD+PART showed more dementia (p < 0.01) and suicide (p < 0.05) than pure PART.

DISCUSSION

Our results advocate a reevaluation of the PART concept and its diagnostic criteria.

HIGHLIGHTS

We investigated 1589 forensic autopsy cases to investigate the features of primary age-related tauopathy (PART). PART peaked in people in their 60s in our study. Many PART cases over 80s had comorbid pathologies in addition to neurofibrillary tangles pathology. Argyrophilic grain disease and Lewy pathology significantly affected dementia and suicide rates in PART. Our results suggest that the diagnostic criteria of PART need to be reconsidered.

Sex and gender differences in cognitive resilience to aging and Alzheimer's disease

Sex and gender-biological and social constructs-significantly impact the prevalence of protective and risk factors, influencing the burden of Alzheimer's disease (AD; amyloid beta and tau) and other pathologies (e.g., cerebrovascular disease) which ultimately shape cognitive trajectories. Understanding the interplay of these factors is central to understanding resilience and resistance mechanisms explaining maintained cognitive function and reduced pathology accumulation in aging and AD. In this narrative review, the ADDRESS! Special Interest Group (Alzheimer's Association) adopted a multidisciplinary approach to provide the foundations and recommendations for future research into sex- and gender-specific drivers of resilience, including a sex/gender-oriented review of risk factors, genetics, AD and non-AD pathologies, brain structure and function, and animal research. We urge the field to adopt a sex/gender-aware approach to resilience to advance our understanding of the intricate interplay of biological and social determinants and consider sex/gender-specific resilience throughout disease stages. HIGHLIGHTS: Sex differences in resilience to cognitive decline vary by age and cognitive status. Initial evidence supports sex-specific distinctions in brain pathology. Findings suggest sex differences in the impact of pathology on cognition. There is a sex-specific change in resilience in the transition to clinical stages. Gender and sex factors warrant study: modifiable, immune, inflammatory, and vascular.

Reduced rapid eye movement sleep in late middle-aged and older apolipoprotein E ɛ4 allele carriers

STUDY OBJECTIVES

Apolipoprotein E ɛ4 (APOE4) is the strongest genetic risk factor for Alzheimer's disease (AD). In addition, APOE4 carriers may exhibit sleep disturbances, but conflicting results have been reported, such that there is no clear consensus regarding which aspects of sleep are impacted. Our objective was to compare objective sleep architecture between APOE4 carriers and non-carriers, and to investigate the modulating impact of age, sex, cognitive status, and obstructive sleep apnea (OSA).

METHODS

A total of 198 dementia-free participants aged >55 years old (mean age: 68.7 ± 8.08 years old, 40.91% women, 41 APOE4 carriers) were recruited in this cross-sectional study. They underwent polysomnography, APOE4 genotyping, and a neuropsychological evaluation. ANCOVAs assessed the effect of APOE4 status on sleep architecture, controlling for age, sex, cognitive status, and the apnea-hypopnea index. Interaction terms were added between APOE4 status and covariates.

RESULTS

Rapid eye movement (REM) sleep percentage (F = 9.95, p = .002, ηp2 = 0.049) and duration (F = 9.23, p = .003, ηp2 = 0.047) were lower in APOE4 carriers. The results were replicated in a subsample of 112 participants without moderate-to-severe OSA. There were no significant interactions between APOE4 status and age, sex, cognitive status, and OSA in the whole sample.

CONCLUSIONS

Our results show that APOE4 carriers exhibit lower REM sleep duration, including in cognitively unimpaired individuals, possibly resulting from early neurodegenerative processes in regions involved in REM sleep generation and maintenance.

Associations of endogenous estrogens, plasma Alzheimer's disease biomarkers, and APOE4 carrier status on regional brain volumes in postmenopausal women

Background

Women carrying the APOE4 allele are at greater risk of developing Alzheimer's disease (AD) from ages 65-75 years compared to men. To better understand the elevated risk conferred by APOE4 carrier status among midlife women, we investigated the separate and interactive associations of endogenous estrogens, plasma AD biomarkers, and APOE4 carrier status on regional brain volumes in a sample of late midlife postmenopausal women.

Methods

Participants were enrolled in MsBrain, a cohort study of postmenopausal women (n = 171, mean age = 59.4 years, mean MoCA score = 26.9; race = 83.2% white, APOE4 carriers = 40). Serum estrone (E1) and estradiol (E2) levels were assessed using liquid chromatography-tandem mass spectrometry. APOE genotype was determined using TaqMan SNP genotyping assays. Plasma AD biomarkers were measured using single molecule array technology. Cortical volume was measured and segmented by FreeSurfer software using individual T1w MPRAGE images. Multiple linear regression models were conducted to determine whether separate and interactive associations between endogenous estrogen levels, plasma AD biomarkers (Aβ42/Aβ40, Aβ42/p-tau181), and APOE4 carrier status predict regional brain volume (21 regions per hemisphere, selected a priori); and, whether significant interactive associations between estrogens and AD biomarkers on brain volume differed by APOE4 carrier status.

Results

There was no main effect of APOE4 carrier status on regional brain volumes, endogenous estrogen levels, or plasma AD biomarkers. Estrogens did not associate with regional brain volumes, except for positive associations with left caudal middle frontal gyrus and fusiform volumes. The interactive association of estrogens and APOE4 carrier status on brain volume was not significant for any region. The interactive association of estrogens and plasma AD biomarkers predicted brain volume of several regions. Higher E1 and E2 were more strongly associated with greater regional brain volumes among women with a poorer AD biomarker profile (lower Aβ42/40, lower Aβ42/p-tau181 ratios). In APOE4-stratified analyses, these interactions were driven by non-APOE4 carriers.

Conclusion

We demonstrate that the brain volumes of postmenopausal women with poorer AD biomarker profiles benefit most from higher endogenous estrogen levels. These findings are driven by non-APOE4 carriers, suggesting that APOE4 carriers may be insensitive to the favorable effects of estrogens on brain volume in the postmenopause.

Effect of apolipoprotein E ε4 and its modification by sociodemographic characteristics on cognitive measures in South Asians from LASI-DAD

BACKGROUND

We investigated the effects of apolipoprotein E (APOE) ε4 and its interactions with sociodemographic characteristics on cognitive measures in South Asians from the Diagnostic Assessment of Dementia for the Longitudinal Aging Study of India (LASI-DAD).

METHODS

Linear regression was used to assess the association between APOE ε4 and global- and domain-specific cognitive function in 2563 participants (mean age 69.6 ± 7.3 years; 53% female). Effect modification by age, sex, and education were explored using interaction terms and subgroup analyses.

RESULTS

APOE ε4 was inversely associated with most cognitive measures (p < 0.05). This association was stronger with advancing age for the Hindi Mental State Examination (HMSE) score (βε4×age = -0.44, p = 0.03), orientation (βε4×age = -0.07, p = 0.01), and language/fluency (βε4×age = -0.07, p = 0.01), as well as in females for memory (βε4×male = 0.17, p = 0.02) and language/fluency (βε4×male = 0.12, p = 0.03).

DISCUSSION

APOE ε4 is associated with lower cognitive function in South Asians from India, with a more pronounced impact observed in females and older individuals.

HIGHLIGHTS

APOE ε4 carriers had lower global and domain-specific cognitive performance. Females and older individuals may be more susceptible to ε4 effects. For most cognitive measures, there was no interaction between ε4 and education.