Alzheimer's disease: its diagnosis and pathogenesis

Physical therapy in the 21st century (Part I): toward practice informed by epidemiology and the crisis of lifestyle conditions

Part I of this two-part introduction to this Special Issue on the practice of physical therapy in the 21st century outlines the epidemiological basis and rationale for evidence-informed physical therapy practice for addressing contemporary health priorities. This evidence emanates from the definition of health by the World Health Organization (WHO) and the International Classification of Functioning (ICF), and WHO and other international databases on the prevalence of lifestyle conditions. Lifestyle conditions include ischemic heart disease, smoking-related conditions, hypertension and stroke, obesity, diabetes, and cancer. Epidemiological data combined with evidence supporting the effectiveness of noninvasive interventions related to physical therapy to address these priorities (e.g., health education and exercise) are highly consistent with the promotion of health and wellness and the ICF. Given their commitment to exploiting effective noninvasive interventions, physical therapists are in a preeminent position to focus on prevention of these disabling and lethal conditions in every client or patient, their cure in some cases, as well as their management. Thus, a compelling argument can be made that clinical competencies in 21st century physical therapy need to include assessment of smoking and smoking cessation (or at least its initiation), basic nutritional assessment and counseling, recommendations for physical activity and exercise, stress assessment and basic stress reduction recommendations, and sleep assessment and basic sleep hygiene recommendations. The physical therapist can then make an informed clinical judgment regarding whether a client or patient needs to be referred to another professional related to one or more of these specialty areas. The prominence of physical therapy as an established health care profession and its unique pattern of practice (prolonged visits over prolonged periods of time) attest further to the fact that physical therapists are uniquely qualified to lead in the assault on lifestyle conditions. Evidence-based physical therapy practiced within the context of epidemiological indicators (i.e., evidence-informed practice) maximally empowers clinicians to promote lifelong health in every person and in turn, the health of communities. This vision of physical therapy's leading role in health promotion and health care in the 21st century holds the promise of reducing the need for invasive health interventions (drugs and surgery). Part II of this introduction describes evidence-based physical therapy practice within this context of evidence-informed practice.

Phosphorylation of soluble tau differs in Pick's disease and Alzheimer's disease brains

Frontotemporal lobar degeneration (FTLD) is a common cause of presenile dementia characterised by behavioural and language disturbances. Pick's disease (PiD) is a subtype of FTLD, which presents with intraneuronal inclusions consisting of hyperphosphorylated tau protein aggregates. Although Alzheimer's disease (AD) is also characterised by tau lesions, these are both histologically and biochemically distinct from the tau aggregates found in PiD. What determines the distinct characteristics of these tau lesions is unknown. As phosphorylated, soluble tau has been suggested to be the precursor of tau aggregates, we compared both the level and phosphorylation profile of tau in tissue extracts of AD and PiD brains to determine whether the differences in the tau lesions are reflected by differences in soluble tau. Levels of soluble tau were decreased in AD but not PiD. In addition, soluble tau was phosphorylated to a greater extent in AD than in PiD and displayed a different phosphorylation profile in the two disorders. Consistently, tau kinases were activated to different degrees in AD compared with PiD. Such differences in solubility and phosphorylation may contribute, at least in part, to the formation of distinct tau deposits, but may also have implications for the clinical differences between AD and PiD.

Laminar profiles of functional activity in the human brain

Functional magnetic resonance imaging (fMRI) data were obtained in human visual cortex using sub-millimeter voxels at a field strength of 3 T. Reliable functional signals were largely confined to the gray matter and these responses measure the retinotopic organization of visual cortex. Functional signals were further characterized with respect to their laminar position within the cortical gray matter. The laminar response profiles during our visuospatial attention task, normalized for cortical thickness, had a stereotypical shape, with a peak in the superficial gray matter and declining in the deeper layers. The thickness of the sheet producing functional signals was in excellent agreement with the estimated structural thickness of the gray matter throughout early visual cortex (error < 0.5 mm). Thickness measurements were highly repeatable from session-to-session (error < 0.4 mm). Hence, it is feasible and useful to use high-resolution fMRI to measure laminar activity profiles. The ability to distinguish signals arising in different lamina has significant potential scientific and clinical applications.

Statins and bone metabolism

3-Hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) are potent inhibitors of cholesterol biosynthesis. Cholesterol-lowering therapy using statins significantly reduces the risk of coronary heart disease. However, extensive use of statins leads to increases of other undesirable as well as beneficial effects, so-called pleiotropic effects. With respect to these effects, statins augment the expression of bone morphogenetic protein-2, a potent simulator of osteoblast differentiation and its activity, and promote mineralization by cultured osteoblasts, indicating that statins have an anabolic effect on bone. Chronic administration of statins in ovariectomized (OVX) rats modestly increases bone mineral density (BMD) of cancellous bone but not of compact bone. In clinical studies, there are conflicting results regarding the clinical benefits of this therapy for the treatment of osteoporosis. Observational studies suggest an association between statin use and reduction in fracture risk. Clinical trials reported no effect of statin treatment on BMD in hip and spine, and on bone turnover. Statins also may influence oral osseous tissues. Administration of statins in combination with osteoporosis therapy appears to improve alveolar bone architecture in the mandibles of OVX rats with maxillary molar extraction. Statins continue to be considered as potential therapeutic agents for patients with osteoporosis and possibly with periodontal disease. Development of new statins that are more specific and potent for bone metabolism will greatly increase the usefulness of these drugs for the treatment of bone diseases.

Effects of scopolamine challenge on regional cerebral blood volume. A pharmacological model to validate the use of contrast enhanced magnetic resonance imaging to assess cerebral blood volume in a canine model of aging

Cognitive impairment resulting from disruption of cholinergic function may occur through modulation of cerebrovascular volume (CBV). In the present study, dynamic susceptibility contrast magnetic resonance imaging (DSC-MRI) was used to examine cerebrovascular volume in young and old dogs during baseline and after administration of a cholinergic antagonist (scopolamine). In the first study, 24 animals (2-15 years of age) were given a baseline scan followed by a second scan after scopolamine administration (30 microg/kg). Gray matter rCBV was significantly higher than white matter rCBV during baseline and scopolamine administration. In the second study a subset of 7 dogs (4 young and 3 old) received scopolamine before anesthesia was induced for a second DSC-MRI scan. Consistent with the first study, gray matter rCBV was significantly higher than white matter rCBV. Scopolamine administered before anesthesia however, resulted in higher rCBV values compared to baseline in cerebral gray matter. Additionally, rCBVs were higher in young dogs at baseline in gray and white matter and marginally higher in gray matter when scopolamine was administered before anesthesia. These results indicate that in the dog, rCBV varies with brain compartment, decreases with age, and that DSC-MRI provides a measure of cerebrovascular function which may be related to age-dependent changes in cognition, brain structure, and neuropathology.

Can dementia be prevented? Brain aging in a population-based context

As a consequence of global aging of the human population, the occurrence of cognitive impairment and dementia is rapidly becoming a significant burden for medical care and public health systems. By the year 2020, the WHO predicts there will be nearly 29 million demented people in both developed and developing countries. Primary and secondary prevention of dementia through individual and population-level interventions could reduce this imminent risk. Vascular risk factors such as type 2 diabetes, hypertension, dietary fat intake, high cholesterol, and obesity have emerged as important influences on the risk of both vascular and Alzheimer's dementia. Understanding the reasons for differences between populations in genetic vulnerability and environmental exposures may help to identify modifiable risk factors that may lead to effective prevention of vascular and Alzheimer's dementia.

Methylenetetrahydrofolate reductase and angiotensin converting enzyme gene polymorphisms in two genetically and diagnostically distinct cohort of Alzheimer patients

The role of methylenetetrahydrofolate reductase (MTHFR) and angiotensin converting enzyme (ACE) gene polymorphisms as risk factors for the occurrence of Alzheimer's disease (AD) is still controversial. In this study, we investigated the common MTHFR C677-->T and ACE insertion/deletion (I/D) gene polymorphisms as risk factors for AD in two genetically and diagnostically distinct cohort of Alzheimer's patients. We analyzed a neuropathologically confirmed American cohort of 124 AD patients and 97 elderly controls, and a clinically diagnosed Italian cohort of 126 probable AD cases, 106 elderly controls, and a community-based sample of 1232 subjects aged under 65 years. No difference was found in polymorphism distribution between cases and controls in both study cohorts. We also tested a possible association between the polymorphisms investigated. No interaction was found between the MTHFR and ACE alleles. Moreover, no association was found for the ACE and MTHFR polymorphisms with age at onset, disease duration and MMSE score at observation. Thus, in our study, MTHFR C677-->T and ACE I/D polymorphisms do not appear to confer an added risk for AD.

General aspects of neurodegeneration

Neurodegenerative diseases are morphologically featured by progressive cell loss in specific vulnerable neuronal populations of the central nervous system, often associated with cytoskeletal protein aggregates forming intracytoplasmic and/or intranuclear inclusions in neurons and/or glial cells. Most neurodegenerative disorders are now classified either according to the hitherto known genetic mechanisms or to the major components of their cellular protein inclusions. The major basic processes inducing neurodegeneration are considered multifactorial ones caused by genetic, environmental, and endogenous factors. They include abnormal protein dynamics with defective protein degradation and aggregation, many of them related to the ubiquitin-proteasomal system, oxidative stress and free radical formation, impaired bioenergetics and mitochondrial dysfunctions, and "neuroinflammatory" processes. These mechanisms that are usually interrelated in complex vitious circles finally leading to programmed cell death cascades are briefly discussed with reference to their pathogenetic role in many, albeit diverse neurodegenerative diseases, like Alzheimer disease, synucleinopathies, tauopathies, and polyglutamine disorders. The impact of protein inclusions on cell dysfunction, activation or prevention of cell death cascades are discussed, but the molecular basis for the underlying disease mechanisms remains to be elucidated.

The pleiotropic effects of HMG-CoA reductase inhibitors: their role in osteoporosis and dementia

HMG-CoA reductase is the rate-limiting enzyme for cholesterol synthesis and its inhibition exerts profound effects on cellular metabolism. Inhibitors of this enzyme are used in clinical practice to lower plasma cholesterol levels and are commonly collectively referred to as 'statins'. A number of in vitro, in vivo animal, and clinical studies suggest that properties of statins other than cholesterol lowering may be of biological importance. These diverse properties are often referred to as 'pleiotropic' and suggest that statins may affect a number of diseases of ageing. In this article we review the biological plausibility and clinical evidence of a role for statins in modulating two diseases of ageing: osteoporosis and dementia (including Alzheimer's disease). In both diseases, there is a sound cellular and laboratory basis for a plausible therapeutic effect of statins. In the case of osteoporosis, there are conflicting data regarding clinical benefit, with both negative and positive results reported. In particular, secondary analyses of randomised, controlled studies have shown no reduction of fracture risk by statins. In the case of dementia there are fewer clinical studies but there is clear anticipated benefit in macrovascular dementias attributable to statin-mediated reduction of the risk of stroke. Overall, there are a lack of prospective, placebo-controlled, randomised data testing statins and modulation of the risk of osteoporosis-related fracture or of clinical dementia, where these are primary outcomes. Until such data are available, the use of statins appears promising but cannot be recommended as a primary therapeutic modality for either condition.