Diagnosis and Management of Autonomic Dysfunction in Dementia Syndromes

The Clinical Role of Heart Rate Variability Assessment in Cognitively Impaired Patients and Its Applicability in Community Care Settings: A Systematic Review of the Literature

Heart rate variability (HRV) correlates well with a person's overall physiological function. Clinically, HRV is successfully used in acute care to identify impending infections, but little is known about its potential in the management of chronic diseases like cognitive decline/dementia. The aim of this study was to identify the best available knowledge about HRV in cognitively impaired populations that might be applied to improve clinical practice in community settings. We conducted a systematic literature search in PubMed, Embase, and Cochrane databases published from January 2009 to August 2022. Eligible studies were selected using Covidence and each study underwent qualitative assessment using the Mixed Method Appraisal Tool. At each stage of selection, each study was reviewed independently by two members of the team, and any disputes were discussed along the way. The literature identified that the brain regions controlling HRV are also those affected by dementias of Alzheimer's type (AD) and Lewy body types (DLB). HRV was impaired in both types, with DLB showing greater impairment in all HRV parameters compared to AD. No studies explored the temporal changes of HRV or its use in the clinical management of people with cognitive impairment (CI). The current lack of standardization of HRV recording and analysis limits its use in clinical practice. HRV may emerge as a potentially useful tool to identify people with early/preclinical memory impairment and help to differentiate AD from DLB. Longitudinal HRV measurement is emerging as a useful way to monitor disease progression and treatment response, and continuous HRV measurement may prove useful in the early identification of sepsis and its complications in patients no longer able to communicate their illness experiences.

Blood pressure variability supersedes heart rate variability as a real-world measure of dementia risk

Blood pressure variability (BPV) and heart rate variability (HRV) have been associated with Alzheimer's Disease and Related Dementias (ADRD) in rigorously controlled studies. However, the extent to which BPV and HRV may offer predictive information in real-world, routine clinical care is unclear. In a retrospective cohort study of 48,204 adults (age 54.9 ± 17.5 years, 60% female) receiving continuous care at a single center, we derived BPV and HRV from routinely collected clinical data. We use multivariable Cox models to evaluate the association of BPV and HRV, separately and in combination, with incident ADRD. Over a median 3 [2.4, 3.0] years, there were 443 cases of new-onset ADRD. We found that clinically derived measures of BPV, but not HRV, were consistently associated with incident ADRD. In combined analyses, only patients in both the highest quartile of BPV and lowest quartile of HRV had increased ADRD risk (HR 2.34, 95% CI 1.44-3.81). These results indicate that clinically derived BPV, rather than HRV, offers a consistent and readily available metric for ADRD risk assessment in a real-world patient care setting. Thus, implementation of BPV as a widely accessible tool could allow clinical providers to efficiently identify patients most likely to benefit from comprehensive ADRD screening.

Clinical impact of a multifaceted intervention aimed at decreasing distress in people living with dementia: evaluating the Reconnect program

Background

To better meet the needs of people living with advanced dementia, Orchard Care Homes, United Kingdom have established an enhanced person focused program, namely the Reconnect program, which provides an enriched psycho-social care to enhance peoples' quality of life and well-being. Here we aimed to review the impact of this program on people living with dementia.

Methods

In this study the implementation of the Reconnect program was evaluated for two six-month periods (April-September 2020 and April-September 2021). The focus of this evaluation was on three key interventions: increasing meaningful occupation and engagement; improving pain identification and management, and reducing constipation. The Reconnect program was conducted in a single for-profit care home. It involved residents with complex dementia needs who previously not responded to support in alternative settings or found previous care ineffective in relieving their distress and reducing risks they pose to themselves or others.

Results

A total of 24 people participated in the program during this evaluation. We observed a substantial increase in engagement in meaningful activity per person, including an increase of outdoor access to fresh air. Pain management improved as evidenced by more standardized pain assessments using the PainChek system and coverage of people with either regular and/or "when required" pain management. Constipation relief also improved. For the two comparison periods, distress responses per resident reduced from 14.5 to 10.6 events and use of regular pain relief increased from 21.7 to 48.1%. Use of "when required" benzodiazepine halved from 6 months average of 46 to 23.2 doses given. Benzodiazepine dose reductions increased from 13.3 to 31.8%, while cessations increased from 20 to 50%. We also observed a reduction from 76.3 to 56.3% in antipsychotic use. Their dose reductions increased from 8.3 to 40% and drug cessation was made in 30% of people using antipsychotics (compared to the first period in which no medication cessation was observed). A 91.7% reduction (i.e., from 36 to 3 events) in safeguarding events related to behaviors was also observed.

Conclusion

Introduction of the Reconnect program, through its interventions focused on meaningful activity engagement, pain management and constipation relief resulted in substantial improvements related to people's distress, safeguarding and psychotropic use.

The role of the autonomic nervous system in cerebral blood flow regulation in stroke: A review

Stroke is a pathophysiological condition which results in alterations in cerebral blood flow (CBF). The mechanism by which the brain maintains adequate CBF in presence of fluctuating cerebral perfusion pressure (CPP) is known as cerebral autoregulation (CA). Disturbances in CA may be influenced by a number of physiological pathways including the autonomic nervous system (ANS). The cerebrovascular system is innervated by adrenergic and cholinergic nerve fibers. The role of the ANS in regulating CBF is widely disputed owing to several factors including the complexity of the ANS and cerebrovascular interactions, limitations to measurements, variation in methods to assess the ANS in relation to CBF as well as experimental approaches that can or cannot provide insight into the sympathetic control of CBF. CA is known to be impaired in stroke however the number of studies investigating the mechanisms by which this occurs are limited. This literature review will focus on highlighting the assessment of the ANS and CBF via indices derived from the analyses of heart rate variability (HRV), and baroreflex sensitivity (BRS), and providing a summary of both clinical and animal model studies investigating the role of the ANS in influencing CA in stroke. Understanding the mechanisms by which the ANS influences CBF in stroke patients may provide the foundation for novel therapeutic approaches to improve functional outcomes in stroke patients.

Association of blood pressure variability during acute care hospitalization and incident dementia

Background and objectives

Recognized as a potential risk factor for Alzheimer's disease and related dementias (ADRD), blood pressure variability (BPV) could be leveraged to facilitate identification of at-risk individuals at a population level. Granular BPV data are available during acute care hospitalization periods for potentially high-risk patients, but the incident ADRD risk association with BPV measured in this setting is unknown. Our objective was to evaluate the relation of BPV, measured during acute care hospitalization, and incidence of ADRD.

Methods

We retrospectively studied adults, without a prior ADRD diagnosis, who were admitted to a large quaternary care medical center in Southern California between January 1, 2013 and December 31, 2019. For all patients, determined BPV, calculated as variability independent of the mean (VIM), using blood pressure readings obtained as part of routine clinical care. We used multivariable Cox proportional hazards regression to examine the association between BP VIM during hospitalization and the development of incident dementia, determined by new ICD-9/10 coding or the new prescription of dementia medication, occurring at least 2 years after the index hospitalization.

Results

Of 81,892 adults hospitalized without a prior ADRD diagnosis, 2,442 (2.98%) went on to develop ADRD (2.6 to 5.2 years after hospitalization). In multivariable-adjusted Cox models, both systolic (HR 1.05, 95% CI 1.00-1.09) and diastolic (1.06, 1.02-1.10) VIM were associated with incident ADRD. In pre-specified stratified analyses, the VIM associations with incident ADRD were most pronounced in individuals over age 60 years and among those with renal disease or hypertension. Results were similar when repeated to include incident ADRD diagnoses made at least 1 or 3 years after index hospitalization.

Discussion

We found that measurements of BPV from acute care hospitalizations can be used to identify individuals at risk for developing a diagnosis of ADRD within approximately 5 years. Use of the readily accessible BPV measure may allow healthcare systems to risk stratify patients during periods of intense patient-provider interaction and, in turn, facilitate engagement in ADRD screening programs.

Severe hypotension during junctional rhythm in a patient with multiple cerebral infarcts

An 82-year-old woman with parkinsonism and Lewy body dementia was re-admitted to our hospital due to convulsions and the recurrence of cerebral infarction. Parasternal transthoracic echocardiography showed normal left ventricular wall thickness and wall motion. To treat marked bradycardia and hypotension, she underwent temporary pacing. However, she lost her consciousness, when her blood pressure could not be measured. Simultaneous electrocardiogram and blood pressure monitoring showed that systolic blood pressure decreased by almost 30 mmHg from sinus rhythm to junctional rhythm. In the present case of acute cerebral infarction, severe hypotension occurred during junctional rhythm possibly contributed by parkinsonism and Lewy body dementia.

Learning objective

As patients with junctional rhythm usually have no or mild symptoms, there are no specific guidelines for its evaluation and treatment. However, severe symptoms such as hypotension, cerebral infarction, loss of consciousness, or breathlessness may occur in some cases. Holter electrocardiogram with 24-hour noninvasive blood pressure monitoring may be helpful in such severe cases.

Cellular basis of learning and memory in the carotid body

The carotid body is the primary peripheral chemoreceptor in the body, and critical for respiration and cardiovascular adjustments during hypoxia. Yet considerable evidence now implicates the carotid body as a multimodal sensor, mediating the chemoreflexes of a wide range of physiological responses, including pH, temperature, and acidosis as well as hormonal, glucose and immune regulation. How does the carotid body detect and initiate appropriate physiological responses for these diverse stimuli? The answer to this may lie in the structure of the carotid body itself. We suggest that at an organ-level the carotid body is comparable to a miniature brain with compartmentalized discrete regions of clustered glomus cells defined by their neurotransmitter expression and receptor profiles, and with connectivity to defined reflex arcs that play a key role in initiating distinct physiological responses, similar in many ways to a switchboard that connects specific inputs to selective outputs. Similarly, within the central nervous system, specific physiological outcomes are co-ordinated, through signaling via distinct neuronal connectivity. As with the brain, we propose that highly organized cellular connectivity is critical for mediating co-ordinated outputs from the carotid body to a given stimulus. Moreover, it appears that the rudimentary components for synaptic plasticity, and learning and memory are conserved in the carotid body including the presence of glutamate and GABAergic systems, where evidence pinpoints that pathophysiology of common diseases of the carotid body may be linked to deviations in these processes. Several decades of research have contributed to our understanding of the central nervous system in health and disease, and we discuss that understanding the key processes involved in neuronal dysfunction and synaptic activity may be translated to the carotid body, offering new insights and avenues for therapeutic innovation.

Assessment of autonomic symptoms may assist with early identification of mild cognitive impairment with Lewy bodies

OBJECTIVES

Autonomic symptoms are a common feature of the synucleinopathies, and may be a distinguishing feature of prodromal Lewy body disease. We aimed to assess whether the cognitive prodrome of dementia with Lewy bodies, mild cognitive impairment (MCI) with Lewy bodies (MCI-LB), would have more severe reported autonomic symptoms than cognitively healthy older adults, with MCI due to Alzheimer's disease (MCI-AD) also included for comparison. We also aimed to assess the utility of an autonomic symptom scale in differentiating MCI-LB from MCI-AD.

METHODS

Ninety-three individuals with MCI and 33 healthy controls were assessed with the Composite Autonomic Symptom Score 31-item scale (COMPASS). Mild cognitive impairment patients also underwent detailed clinical assessment and differential classification of MCI-AD or MCI-LB according to current consensus criteria. Differences in overall COMPASS score and individual symptom sub-scales were assessed, controlling for age.

RESULTS

Age-adjusted severity of overall autonomic symptomatology was greater in MCI-LB (Ratio = 2.01, 95% CI: 1.37-2.96), with higher orthostatic intolerance and urinary symptom severity than controls, and greater risk of gastrointestinal and secretomotor symptoms. MCI-AD did not have significantly higher autonomic symptom severity than controls overall. A cut-off of 4/5 on the COMPASS was sensitive to MCI-LB (92%) but not specific to this (42% specificity vs. MCI-AD and 52% vs. healthy controls).

CONCLUSIONS

Mild cognitive impairment with Lewy bodies had greater autonomic symptom severity than normal ageing and MCI-AD, but such autonomic symptoms are not a specific finding. The COMPASS-31 may therefore have value as a sensitive screening test for early-stage Lewy body disease.

Vestibular-autonomic interactions: beyond orthostatic dizziness

PURPOSE OF REVIEW

This review aims to summarize the current literature describing vestibular-autonomic interactions and to describe their putative role in various disorders' clinical presentations, including orthostatic dizziness and motion sensitivity.

RECENT FINDINGS

The vestibular-autonomic reflexes have long been described as they relate to cardiovascular and respiratory function. Although orthostatic dizziness may be in part related to impaired vestibulo-sympathetic reflex (orthostatic hypotension), there are various conditions that may present similarly. A recent clinical classification aims to improve identification of individuals with hemodynamic orthostatic dizziness so that appropriate recommendations and management can be efficiently addressed. Researchers continue to improve understanding of the underlying vestibular-autonomic reflexes with recent studies noting the insular cortex as a cortical site for vestibular sensation and autonomic integration and modulation. Work has further expanded our understanding of the clinical presentation of abnormal vestibular-autonomic interactions that may occur in various conditions, such as aging, peripheral vestibular hypofunction, traumatic brain injury, and motion sensitivity.

SUMMARY

The vestibular-autonomic reflexes affect various sympathetic and parasympathetic functions. Understanding these relationships will provide improved identification of underlying etiology and drive improved patient management.

Prevalence of Constipation in Elderly and Its Association With Dementia and Mild Cognitive Impairment: A Cross-Sectional Study

Background

Constipation and dementia have similar epidemiological characteristics. Changes in intestinal flora and characteristics of the brain-gut axis play roles in the pathogeneses of the two diseases, suggesting that there may be a close connection between the two. Most of the studies on constipation in dementia patients have focused on the population with α-synucleinopathies [Parkinson’s disease dementia (PDD), dementia with Lewy bodies (DLB)]. Few studies have reported the prevalence of constipation in all-cause dementia and mild cognitive impairment (MCI) populations.

Objective

To assess the prevalence of constipation in patients with all-cause dementia and MCI subtypes and to explore the association between constipation with dementia and MCI subtypes.

Methods

From May 2019 to December 2019, we conducted a population-based cross-sectional survey. A total of 11,743 participants aged 65 or older from nine cities in China were surveyed. Participants underwent a series of clinical examinations and neuropsychological measurements. Constipation, dementia, MCI and MCI subtype were diagnosed according to established criteria through standard diagnostic procedures.

Results

The overall age- and sex-adjusted prevalence of constipation in individuals aged 65 years and older was 14.8% (95% CI, 14.6–15.0). The prevalence rates of constipation were19.2% (95% CI, 17.3–21.0), 19.1% (95% CI, 16.8–21.5), 14.4% (95% CI, 12.8–15.9), and 13.8% (95% CI, 13.0–14.6) in the dementia, non-amnestic (na)-MCI, amnestic (a)-MCI and normal cognition populations, respectively. Multivariate logistic regression analysis showed that higher prevalence of constipation was associated with dementia (p = 0.0.032, OR = 1.18, 95% CI: 1.02–1.38) and na-MCI (p = 0.003, OR = 1.30, 95% CI: 1.09–1.54).

Conclusion

The present study found a high prevalence of constipation in elderly individuals in China, and higher in patients with dementia and na-MCI.

The role of cardiovascular autonomic failure in the differential diagnosis of α-synucleinopathies

The α-synucleinopathies comprise a group of adult-onset neurodegenerative disorders including Parkinson’s disease (PD), multiple system atrophy (MSA), dementia with Lewy bodies (DLB,) and — as a restricted non-motor form — pure autonomic failure (PAF). Neuropathologically, the α-synucleinopathies are characterized by aggregates of misfolded α-synuclein in the central and peripheral nervous system. Cardiovascular autonomic failure is a common non-motor symptom in people with PD, a key diagnostic criterion in MSA, a supportive feature for the diagnosis of DLB and disease-defining in PAF. The site of autonomic nervous system lesion differs between the α-synucleinopathies, with a predominantly central lesion pattern in MSA versus a peripheral one in PD, DLB, and PAF. In clinical practice, overlapping autonomic features often challenge the differential diagnosis among the α-synucleinopathies, but also distinguish them from related disorders, such as the tauopathies or other neurodegenerative ataxias. In this review, we discuss the differential diagnostic yield of cardiovascular autonomic failure in individuals presenting with isolated autonomic failure, parkinsonism, cognitive impairment, or cerebellar ataxia.

The Association Between Hyperhidrosis and Dementia: A Community-Based Research

BACKGROUND

Dementia and hyperhidrosis (HH) are common in the elderly while there is little research to investigate the association between them.

OBJECTIVE

To clarify a possible association between HH and dementia in population of adults ≥65 years old in China.

METHODS

A cross-sectional survey for elderly adults ≥65 years old was conducted from April to December 2019. A total of 5,958 participants were analyzed after two phases investigation. Goodness-of-fit tests (Pearson and deviance) were used to estimate the dispersion parameter and examine the adequacy of the models. Logistic and linear regression analyses were used to evaluate the association between HH and dementia.

RESULTS

The overall prevalence of all-cause dementia was 10.17%, that of dementia with Lewy bodies (DLB) was 1.41%, and HH was 14.97%. Prevalence rates of HH were higher in participants with dementia and DLB. There was a significant positive relationship between HH duration and MMSE score (r = 0.207, p < 0.001, Durbin-Watson test = 1.806). Participants with HH were 1.275 (95% CI: 1.015-1.601, p = 0.037) times to have dementia, and 3.616 (95% CI: 2.267-5.767, p < 0.001) times to suffer from DLB than those without HH. Pearson and deviance chi square tests did not indicate overdispersion (p > 0.05 in the logistic regression models).

CONCLUSION

HH was common in the Chinese population ≥65 years old. It can increase the risk of dementia, particularly in DLB, in the elderly. It is important to improve the awareness of HH among dermatologists and neurologists.

Lewy body dementia: Ursodeoxycholic acid as a putative treatment for gastrointestinal dysfunction

The autonomic nervous system (ANS) is a part of the peripheral nervous system that regulates internal organs function at an involuntary unconscious level. Recent evidence has shown that autonomic dysfunction is a common feature of Lewy body dementia (LBD). A wide range of autonomic symptoms may occur in LBD, which are correlated with poor prognosis. However, there is still no evidence-based approach to developing the best therapeutic strategy for autonomic dysfunction (particularly gastrointestinal symptoms) among LBD patients. This paper was intended to present a new perspective on ursodeoxycholic acid and its potential effects for treating gastrointestinal dysfunction in LBD patients.

Autonomic Imbalance and Risk of Dementia and Stroke: The Framingham Study

Background and Purpose

The autonomic nervous system has been implicated in stroke and dementia pathophysiology. High resting heart rate and low heart rate variability indicate the effect of autonomic imbalance on the heart. We examined the associations of resting heart rate and heart rate variability with incident stroke and dementia in a community-based cohort of middle- and old-aged adults.

Methods

The study sample included 1581 participants aged >60 years and 3271 participants aged >45 years evaluated for incident dementia and stroke, respectively, who participated in the Framingham Offspring cohort third (1983–1987) examination and had follow-up for neurology events after the seventh (1998–2001) examination. Heart rate variability was assessed through the standard deviation (SD) of normal-to-normal RR intervals and the root mean square of successive differences between normal heartbeats from 2-hour Holter monitor. Participants were followed-up for stroke and dementia incidence from exam 7 to a maximum of 10 years. Cox regression models were used to assess the link of resting heart rate and heart rate variability with stroke and dementia risk while adjusting for potential confounders, and interactions with age and sex were assessed.

Results

Of the dementia (mean age, 55±6 years, 46% men) and stroke (mean age, 48±9 years, 46% men) samples, 133 and 127 developed dementia and stroke, respectively, during the follow-up. Overall, autonomic imbalance was not associated with dementia risk. However, age modified the associations such that SD of normal-to-normal intervals and root mean square of successive differences were associated with dementia risk in older people (hazard ratio [HR] [95% CI] per 1SD, 0.61 [0.38–0.99] and HR [95% CI] per 1SD, 0.34 [0.15–0.74], respectively). High resting heart rate was associated with increased stroke risk (HR [95% CI] per 10 bpm, 1.18 [1.01–1.39]), and high SD of normal-to-normal intervals was associated with lower stroke risk in men (HR [95% CI] per 1SD, 0.46 [0.26–0.79]) but not women (HR [95% CI] per 1SD, 1.25 [0.88–1.79]; P for interaction=0.003).

Conclusions

Some measures of cardiac autonomic imbalance may precede dementia and stroke occurrence, particularly in older ages and men, respectively.

Are patients with cognitive impairment fit to fly? Current evidence and practical recommendations

BACKGROUND

The worldwide prevalence of dementia is increasing and represents a major public health concern. In the last decades, air travel services have undergone an impressive expansion and one of ten passengers is aged 65 years and older. While air travel can be stressful at all ages and health conditions, older individuals with cognitive impairment carry a greater risk for air-travel-related complications. Consequently, demands to general practitioners for assessing their older patient's fitness to fly are increasing.

METHODS

We conducted a search of the literature in PubMed on the impact of in-flight environmental changes on passengers with cognitive impairment and possible resulting complications. This set the base for a discussion on pharmacological and non-pharmacological interventions aimed at preventing in-flight complications in this vulnerable population.

RESULTS

While our research strategy identified a total of 11 articles related to older age and air travel, only three focused on passengers with cognitive impairment. Our literature review showed that the airplane environment may lead to a large spectrum of symptoms in passengers of all age groups. However, passengers with cognitive impairment due to neurodegenerative diseases are at increased risk for experiencing the most extreme symptoms such as acute confusional state. Non-pharmacological and pharmacological interventions at different stages of the travel process (before, during and after) can help prevent complications in this vulnerable population.

CONCLUSION

The decision to let a patient with cognitive impairment fly requires a solid understanding of the in-flight environmental changes and their impact on older patients with cognitive impairment. Moreover, a sound weighing of the risks and benefits while considering different aspects of the patient's history is demanded. In this regard, the role of the treating physicians and caregivers is essential along with the support of the medical department of the airline.

The Role of Glial Mitochondria in α-Synuclein Toxicity

The abnormal accumulation of alpha-synuclein (α-syn) aggregates in neurons and glial cells is widely known to be associated with many neurodegenerative diseases, including Parkinson's disease (PD), Dementia with Lewy bodies (DLB), and Multiple system atrophy (MSA). Mitochondrial dysfunction in neurons and glia is known as a key feature of α-syn toxicity. Studies aimed at understanding α-syn-induced toxicity and its role in neurodegenerative diseases have primarily focused on neurons. However, a growing body of evidence demonstrates that glial cells such as microglia and astrocytes have been implicated in the initial pathogenesis and the progression of α-Synucleinopathy. Glial cells are important for supporting neuronal survival, synaptic functions, and local immunity. Furthermore, recent studies highlight the role of mitochondrial metabolism in the normal function of glial cells. In this work, we review the complex relationship between glial mitochondria and α-syn-mediated neurodegeneration, which may provide novel insights into the roles of glial cells in α-syn-associated neurodegenerative diseases.

Autonomic function in amnestic and non-amnestic mild cognitive impairment: spectral heart rate variability analysis provides evidence for a brain-heart axis

Mild cognitive impairment (MCI) is a heterogeneous syndrome with two main clinical subtypes, amnestic (aMCI) and non-amnestic (naMCI). The analysis of heart rate variability (HRV) is a tool to assess autonomic function. Cognitive and autonomic processes are linked via the central autonomic network. Autonomic dysfunction entails several adverse outcomes. However, very few studies have investigated autonomic function in MCI and none have considered MCI subtypes or the relationship of HRV indices with different cognitive domains and structural brain damage. We assessed autonomic function during an active orthostatic challenge in 253 oupatients aged ≥ 65, [n = 82 aMCI, n = 93 naMCI, n = 78 cognitively normal (CN), neuropsychologically tested] with power spectral analysis of HRV. We used visual rating scales to grade cerebrovascular burden and hippocampal/insular atrophy (HA/IA) on neuroimaging. Only aMCI showed a blunted response to orthostasis. Postural changes in normalised low frequency (LF) power and in the LF to high frequency ratio correlated with a memory test (positively) and HA/IA (negatively) in aMCI, and with attention/executive function tests (negatively) and cerebrovascular burden (positively) in naMCI. These results substantiate the view that the ANS is differentially impaired in aMCI and naMCI, consistently with the neuroanatomic substrate of Alzheimer's and small-vessel subcortical ischaemic disease.

Unsuspected Involvement of Spinal Cord in Alzheimer Disease

Objective: Brain atrophy is an established biomarker for dementia, yet spinal cord involvement has not been investigated to date. As the spinal cord is relaying sensorimotor control signals from the cortex to the peripheral nervous system and vice-versa, it is indeed a very interesting question to assess whether it is affected by atrophy due to a disease that is known for its involvement of cognitive domains first and foremost, with motor symptoms being clinically assessed too. We, therefore, hypothesize that in Alzheimer's disease (AD), severe atrophy can affect the spinal cord too and that spinal cord atrophy is indeed an important in vivo imaging biomarker contributing to understanding neurodegeneration associated with dementia. Methods: 3DT1 images of 31 AD and 35 healthy control (HC) subjects were processed to calculate volume of brain structures and cross-sectional area (CSA) and volume (CSV) of the cervical cord [per vertebra as well as the C2-C3 pair (CSA23 and CSV23)]. Correlated features (ρ > 0.7) were removed, and the best subset identified for patients' classification with the Random Forest algorithm. General linear model regression was used to find significant differences between groups (p ≤ 0.05). Linear regression was implemented to assess the explained variance of the Mini-Mental State Examination (MMSE) score as a dependent variable with the best features as predictors. Results: Spinal cord features were significantly reduced in AD, independently of brain volumes. Patients classification reached 76% accuracy when including CSA23 together with volumes of hippocampi, left amygdala, white and gray matter, with 74% sensitivity and 78% specificity. CSA23 alone explained 13% of MMSE variance. Discussion: Our findings reveal that C2-C3 spinal cord atrophy contributes to discriminate AD from HC, together with more established features. The results show that CSA23, calculated from the same 3DT1 scan as all other brain volumes (including right and left hippocampi), has a considerable weight in classification tasks warranting further investigations. Together with recent studies revealing that AD atrophy is spread beyond the temporal lobes, our result adds the spinal cord to a number of unsuspected regions involved in the disease. Interestingly, spinal cord atrophy explains also cognitive scores, which could significantly impact how we model sensorimotor control in degenerative diseases with a primary cognitive domain involvement. Prospective studies should be purposely designed to understand the mechanisms of atrophy and the role of the spinal cord in AD.