Derangement in stress response of apolipoprotein E-deficient mice

Understanding the relationships between physiological and psychosocial stress, cortisol and cognition

Stress is viewed as a state of real or perceived threat to homeostasis, the management of which involves the endocrine, nervous, and immune systems. These systems work independently and interactively as part of the stress response. The scientific stress literature, which spans both animal and human studies, contains heterogeneous findings about the effects of stress on the brain and the body. This review seeks to summarise and integrate literature on the relationships between these systems, examining particularly the roles of physiological and psychosocial stress, the stress hormone cortisol, as controlled by the hypothalamic-pituitary-adrenal (HPA) axis, and the effects of stress on cognitive functioning. Health conditions related to impaired HPA axis functioning and their associated neuropsychiatric symptoms will also be considered. Lastly, this review will provide suggestions of clinical applicability for endocrinologists who are uniquely placed to measure outcomes related to endocrine, nervous and immune system functioning and identify areas of intervention.

Psychosocial stress and cannabinoid drugs affect acetylation of α-tubulin (K40) and gene expression in the prefrontal cortex of adult mice

The dynamics of neuronal microtubules are essential for brain plasticity. Vesicular transport and synaptic transmission, additionally, requires acetylation of α-tubulin, and aberrant tubulin acetylation and neurobiological deficits are associated. Prolonged exposure to a stressor or consumption of drugs of abuse, like marihuana, lead to neurological changes and psychotic disorders. Here, we studied the effect of psychosocial stress and the administration of cannabinoid receptor type 1 drugs on α-tubulin acetylation in different brain regions of mice. We found significantly decreased tubulin acetylation in the prefrontal cortex in stressed mice. The impact of cannabinoid drugs on stress-induced microtubule disturbance was investigated by administration of the cannabinoid receptor agonist WIN55,212–2 and/or antagonist rimonabant. In both, control and stressed mice, the administration of WIN55,212–2 slightly increased the tubulin acetylation in the prefrontal cortex whereas administration of rimonabant acted antagonistically indicating a cannabinoid receptor type 1 mediated effect. The analysis of gene expression in the prefrontal cortex showed a consistent expression of ApoE attributable to either psychosocial stress or administration of the cannabinoid agonist. Additionally, ApoE expression inversely correlated with acetylated tubulin levels when comparing controls and stressed mice treated with WIN55,212–2 whereas rimonabant treatment showed the opposite.

RNA-Seq Mouse Brain Regions Expression Data Analysis: Focus on ApoE Functional Network

ApoE expression status was proved to be a highly specific marker of energy metabolism rate in the brain. Along with its neighbor, Translocase of Outer Mitochondrial Membrane 40 kDa (TOMM40) which is involved in mitochondrial metabolism, the corresponding genomic region constitutes the neuroenergetic hotspot. Using RNA-Seq data from a murine model of chronic stress a significant positive expression coordination of seven neighboring genes in ApoE locus in five brain regions was observed. ApoE maintains one of the highest absolute expression values genome-wide, implying that ApoE can be the driver of the neighboring gene expression alteration observed under stressful loads. Notably, we revealed the highly statistically significant increase of ApoE expression in the hypothalamus of chronically aggressive (FDR < 0.007) and defeated (FDR < 0.001) mice compared to the control. Correlation analysis revealed a close association of ApoE and proopiomelanocortin (Pomc) gene expression profiles implying the putative neuroendocrine stress response background of ApoE expression elevation therein.

Interactions between the apolipoprotein E ε4 allele status and adverse childhood experiences on depressive symptoms in older adults

BACKGROUND

The influence of childhood adversity on depression is modulated by genetic vulnerability. The apolipoprotein E ε4 (APOE-ε4) allele is a strong genetic risk factor for Alzheimer's disease (AD). Because late-life depressive symptoms could be a part of the preclinical course of AD, the APOE-ε4 allele may contribute to depression in old age.

OBJECTIVE

The aim of this study was to evaluate whether an APOE-ε4 carrier status was associated with depressive symptoms in older adults and to detect the gene-environment interaction between APOE-ε4 status and childhood adversity in relation to depressive symptoms in old age.

METHOD

The participants consisted of 137 older adults (age range 50-70) without any psychiatric history or clinically significant cognitive impairment. APOE genotypes and measures of childhood adversity and depressive symptoms were obtained.

RESULTS

There was a significant positive association between adverse childhood experiences (ACE) scores and depressive symptoms (B=0.60; 95% CI=0.26, 0.93 for a 1 score increase in ACE scores; p=0.001). Although APOE-ε4 status per se was not associated with depressive symptoms, there was a significant interaction of the ACE scores with the APOE genotype in relation to depressive symptoms (B=0.78; 95% CI=0.02, 1.55; p=0.044). There was a significantly higher effect of childhood adversity on depressive symptoms in APOE-ε4 carriers than non-carriers (t=2.13, p=0.035).

CONCLUSIONS

Our results suggest that the APOE-ε4 may modulate the association between childhood adversity and depressive symptoms in older adults. However, more research in a larger sample is needed to gain a better understanding of the relationship between the APOE-ε4, childhood adversity, and depression.

Molecular neuropathogenesis of Alzheimer's disease: an interaction model stressing the central role of oxidative stress

Alzheimer's disease (AD) exhibits a complex etiology that simultaneously manifests as a complex cellular, neurobiological, molecular, anatomic-physiological and clinical entity. Other significant psychiatric conditions, such as depression and schizophrenia, may also present with complex and concurrent clinical and/or molecular phenotypes. These neuropsychiatric pathologies also originate from both environmental and genetic factors. We analyzed the molecular phenotypes of AD and discuss them with respect to the classical theories, which we integrated into mechanisms that share molecular and/or anatomical connections. Based on these mechanisms, we propose an interaction model and discuss the model in light of studies that refute or support it. Given the spectrum of AD phenotypes, we limit the scope of our discussion to a few, which facilitates concrete analysis. In addition, the study of specific, individual pathogenic phenotypes may be critical to defining the complex mechanisms leading to AD, thereby improving strategies for developing novel therapies.

The effects of prolonged stress and APOE genotype on memory and cortisol in older adults

BACKGROUND

Chronic elevations in cortisol associated with prolonged stress have been associated with memory loss, as has the apolipoprotein E gene (APOE-epsilon4) genotype. Combined effects of stress and APOE status on memory and cortisol in humans have not been studied.

METHODS

A semistructured interview with standardized scoring was used to measure stress level and univariate analysis of variance to assess effects of stress and APOE-epsilon4 status on memory and salivary cortisol in 91 nondemented subjects (mean age 78.8 years).

RESULTS

Low-stress subjects performed better than high-stress subjects on delayed recall of stories (p = .04), word lists (p = .02), and visual designs (p = .04). APOE-epsilon4-negative subjects obtained better scores than epsilon4-positive subjects on immediate (p = < .01) and delayed (p < .01) recall of visual designs. Significant stress by APOE-epsilon4 interaction effects on memory (p = .03) and cortisol (p < .01) resulted from consistently worse memory and higher cortisol concentrations in the high stress, epsilon4-positive group.

CONCLUSIONS

These findings are consistent with a model in which prolonged exposure of older, nondemented individuals to stress in the presence of an epsilon4 allele leads to memory decline. Further studies will assess whether stress and APOE-epsilon4 interact to increase the risk of developing Alzheimer's disease.

Stress and ageing interactions: A paradox in the context of shared etiological and physiopathological processes

Gerontology has made considerable progress in the understanding of the mechanisms underlying the ageing process and age-related neurodegenerative disorders. However, ways to improve quality of life in the elderly remain to be elucidated. It is now clear that stress and the ageing process share a number of underlying mechanisms bound in a very close, if not indissociable, relationship. The ageing process is regulated by the factors underlying the ability to adjust to stress, whilst stress has an influence on the life span and the quality of ageing. In addition, the ability to cope with stress in adulthood predicts life expectancy and quality of life at senescence. The ageing process and stress also share several common mechanisms, particularly in relation to the energy factor. Stress consumes energy and ageing may be considered as a cost of the energy expended to deal with the stressors to which the body is exposed throughout its lifetime. This suggests that the ageing process is associated with and/or a consequence of a long-lasting activation of the major stress responsive systems. However, despite common features, the interaction between stress and the ageing process gives rise to some paradoxes. Stress can either diminish or exacerbate the ageing process just as the ageing process can worsen or counter the effects of stress. There has been little attempt to understand how ageing and stress might interact to promote "successful" or pathological ageing. A key factor in this respect is the individual's ability to adapt to stress. Viewed from this angle, the quality of life of aged subjects may be improved through therapy designed to improve the tolerance to stress.

Activity changes and marked stereotypic behavior precede Aβ pathology in TgCRND8 Alzheimer mice

Alzheimer's disease (AD) is not only characterized by cognitive decline and neuropathological changes, but also by non-cognitive behavioral symptoms like restlessness, sleep disturbance, and wandering. These symptoms are categorized in the "Behavioral and Psychological Symptoms of Dementia" (BPSD). We investigated transgenic and wildtype mice of an APP transgenic mouse model of AD (TgCRND8) with respect to 24 h activity and spontaneous home cage behavior at 30, 60, 90 and 120 days of age. At all test days, transgenic and wildtype animals differed significantly with respect to activity patterns. In addition, activity rhythms changed distinctly in transgenic mice with increasing age. Transgenic mice also clearly showed more stereotypic behavior, which correlated significantly at 90 and 120 days of age with elevated corticosterone metabolite concentrations in fecal samples. Activity patterns in TgCRND8 mice resemble altered rhythms of activity in AD patients. Stereotypic behaviors may be caused by the same mechanisms as non-cognitive behavioral symptoms of AD. Thus, it is likely that analogies to BPSD that precede Abeta pathology are found in APP-overexpressing TgCRND8 mice.

Apolipoprotein E protects against oxidative stress in mixed neuronal-glial cell cultures by reducing glutamate toxicity

Apolipoprotein E (ApoE) deficiency has been shown to adversely affect outcome after transient cerebral ischemia and head trauma. Since oxidative stress contributes to these injuries, the ability of ApoE to reduce irreversible oxidative damage was studied in primary mixed neuronal-glial cell cultures. Cells (13-16 days in vitro) were exposed to 50 microM hydrogen peroxide (H2O2) for 30 min, and toxicity was determined by the release of lactate dehydrogenase (LDH) 24 h after exposure. The presence of recombinant human ApoE2 (100, 300, or 1000 nM) in the culture media partially protected against oxidative injury. This protection was not reversed by pre-treatment with receptor associated protein. The NMDA receptor antagonist, MK-801, also provided partial protection against H2O2 toxicity. The degree of protection was similar to that conferred by ApoE treatment. The protective effects of ApoE and MK-801 were not additive; no ApoE protection was observed in cultures treated with MK-801 prior to H2O2 exposure. ApoE treatment had no effect on H2O2 stimulated glutamate release, but did increase the rate of glutamate uptake via the high affinity glutamate transporter in H2O2 treated cultures. Pre-treatment with ApoE also conferred partial protection against glutamate-induced LDH release. Taken together, these findings suggest that ApoE protects mixed neuronal-glial cell cultures against irreversible oxidative injury from H2O2 by reducing secondary glutamate excitotoxicity.

The apolipoprotein E epsilon4 allele and antidepressant efficacy in cognitively intact elderly depressed patients

BACKGROUND

Patients vary in response to antidepressant medications. Apolipoprotein E (APOE) genotype affects vulnerability to stress and risk for cognitive impairment. We sought to determine if the APOE epsilon4 allele influences response in geriatric depression to mirtazapine and paroxetine, two frequently prescribed antidepressants. We hypothesized that epsilon4 carriers would show impaired antidepressant response.

METHODS

The study was a double-blind, randomized, 8-week trial with a 16-week extension phase involving 246 cognitively intact patients aged 65 years or older with major depression. Patients were treated with mirtazapine 15-45 mg (n = 124) or paroxetine 20-40 mg (n = 122). The outcome measures were the Hamilton Depression Rating Scale, the Geriatric Depression Scale, and the Clinical Global Impression Scale. APOE genotype was determined by restriction isotyping.

RESULTS

Patients carrying the epsilon4 allele showed a rapid onset of mirtazapine action, whereas paroxetine-treated patients with the epsilon4 allele were slow to respond. This difference could not be attributed to dosage, compliance, severity of adverse events, ethnicity, baseline depression or cognition, gender, or age.

CONCLUSIONS

The APOE epsilon4 allele may affect antidepressant treatment outcome, but the effect depends on the medication. Further studies should determine if this result applies to other samples and medications.

Apolipoprotein E knockout mice display procedural deficits in the Morris water maze: analysis of learning strategies in three versions of the task

Apolipoprotein E knockout (apoEKO) mice have been shown to be impaired in the spatial Morris water maze (MWM). However, several groups failed to replicate this finding. One reason for this inconsistency may stem from variations in the experimental protocols and environment between laboratories. In the present study, we have tested if age and variations in protocol implementation that specifically affect salience of the visual extramaze cues influence performance and navigational strategies in the MWM. We tested three- and 12-month-old apoEKO and wild type mice in three versions of the MWM differing on the availability of visual extramaze cues: (1) salient cues, (2) diffuse cues, and (3) absence of cues. Our results show that the presence of salient cues enhances acquisition performance of wild type, but not apoEKO mice in the MWM. This effect was restricted to the acquisition phase since apoEKO mice reached a level of performance that was comparable to that of controls toward the end of the task. No significant differences were detected between apoEKO and controls in either the diffuse cues or absence of cues paradigms. Thigmotaxic tendencies were observed in apoEKO mice and correlated high latency scores. Thigmotaxis may have interfered with the initial ability to engage in a proficient navigational strategy. These findings suggest that, in contrast to what has been proposed in the past, apoEKO mice appear not to be impaired in spatial memory per se but are deficient in a procedural component of the MWM. Furthermore, the procedural deficit and corresponding thigmotaxic tendencies of apoEKO mice appeared to increase with age. Taken together, these findings confirm our hypothesis that age and variations in experimental protocols can influence MWM performances.

Differential effect of corticosterone on spatial learning abilities in apolipoprotein E knockout and C57BL/6J mice

Previously, we found that repeated exposure to predator stress corrected the deficit in spatial learning of apolipoprotein E-knockout (apoE0/0) mice, but impaired cognitive performance of wild-type mice. Here we show that elevated corticosterone concentrations, accomplished by subcutaneously implanted pellets, results in similar genotype-related effects on water maze learning: while apoE0/0 mice improved their spatial learning abilities, wild-type mice (C57/Bl6J) became impaired. These results suggest that corticosterone mediates the lasting effects of environmental challenges on apoE-genotype related cognitive performance.

Reversal of cognitive deficit of apolipoprotein E knockout mice after repeated exposure to a common environmental experience

This study tests the hypothesis that a history of common stressful experiences further promotes the cognitive deficit of apolipoprotein E (apoE)-knockout mice, an animal model to study aspects of Alzheimer's disease. In experiment 1, apoE-knockout and wild-type mice were repeatedly subjected to an environmental challenge (i.e. exposure to rats) and the effect was monitored on Morris water maze performance. Naive apoE-knockout mice were impaired, but surprisingly after rat stress their water maze performance improved and switched to a goal-directed search strategy. Rat stress induced in wild-type mice spatial learning deficits and an inefficient search strategy. Swim ability was not affected by rat stress and under basal conditions measures for locomotion and anxiety were similar for both genotypes. In experiments 2 and 3, we found that the rat stress paradigm attenuated the elevation of basal and stress-induced corticosterone concentrations in the apoE-knockout mice towards concentrations observed in wild-type mice. The expression of hippocampal mineralocorticoid and glucocorticoid receptor mRNA was similar in both genotypes, but in response to rat stress, the level of glucocorticoid receptor mRNA increased selectively in the CA1 pyramidal field. In conclusion, repeated exposure to a common environmental experience did abolish and reverse the difference in cognitive performance and corticosterone concentrations of apoE-knockout and wild-type mice.

Apolipoprotein E epsilon4 allele affects the relationship between stress and depression in caregivers of patients with Alzheimer's disease

We examined the effect of the apolipoprotein E (apo E) epsilon4 allele on the relationship between self-reported stress and mood in caregivers of patients with Alzheimer's disease. Eighty-six female subjects between the ages of 28 and 82 years who were community-dwelling AD patient caregivers participated in the study. A cross-sectional analysis of stress and mood was performed using the Revised Memory and Behavior Problem Checklist and the Geriatric Depression Scale. All subjects were evaluated for normal cognitive function (Mini-Mental Status Examination) and apo E genotype. The results indicated that increased levels of stress were associated with increased levels of depressive symptoms in nondemented caregivers with the epsilon4 allele. This relationship was not observed in caregivers without the epsilon4 allele. These results suggest that carriers of the epsilon4 allele may respond differently to psychological stress than do individuals without the epsilon4 allele.

Repeated exposure to rats has persistent genotype-dependent effects on learning and locomotor activity of apolipoprotein E knockout and C57Bl/6 mice

Recently we have shown that an experimentally controlled encounter of mice with rats ("rat stress") some time before actual behavioural testing either abolished or induced behavioural deficits in the Morris water maze, depending on the genotype of the mice: apolipoprotein E knockout mice (apoE0/0) and wild type mice. Here we report that previous rat stress: (i) facilitated learning of a circular hole board task in apoE0/0 mice and impaired learning in wild type mice, thereby abolishing genotype-dependent differences; (ii) although both genotypes preferred the dark compartment when tested in a light/dark-preference task 3 months after rat stress, locomotor activity was reduced in apoE0/0 and increased in wild type mice, thus genotype differences were amplified; (iii) both genotypes responded with a differential regulation of bodyweight during exposure to rats, which persisted for 3 months: apoE0/0 mice decreased while wild type mice increased their body weight; (iv) the high emotional reactivity (defecation boli) measured during behavioural tasks was not affected in apoE0/0 mice, whereas a decrease was observed in wild type mice. Thus, pre-experimental confrontation of mice with rats shifts behaviour and physiological responses and eliminates some of the genotype-dependent differences.

Hypothalamic-pituitary-adrenal dysfunction in Apoe(-/-) mice: possible role in behavioral and metabolic alterations

Several neurological diseases are frequently accompanied by dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis. The HPA axis regulates the secretion of glucocorticoids (GCs), which play important roles in diverse brain functions, including cognition, emotion, and feeding. Under physiological conditions, GCs are adaptive and beneficial; however, prolonged elevations in GC levels may contribute to neurodegeneration and brain dysfunction. In the current study, we demonstrate that apolipoprotein E (apoE) deficiency results in age-dependent dysregulation of the HPA axis through a mechanism affecting primarily the adrenal gland. Apoe(-/-) mice, which develop neurodegenerative alterations as they age, had an age-dependent increase in basal adrenal corticosterone content and abnormally increased plasma corticosterone levels after restraint stress, whereas their plasma and pituitary adrenocorticotropin levels were either unchanged or lower than those in controls. HPA axis dysregulation was associated with behavioral and metabolic alterations. When anxiety levels were assessed in the elevated plus maze, Apoe(-/-) mice showed more anxiety than wild-type controls. Apoe(-/-) mice also showed reduced activity in the open field. Finally, Apoe(-/-) mice showed age-dependent increases in food and water intake, stomach and body weights, and decreases in brown and white adipose tissues. These results support a key role for apoE in the tonic inhibition of steroidogenesis and HPA axis activity and have important implications for the behavioral analysis of Apoe(-/-) mice.

A unifying hypothesis of Alzheimer's disease. III. Risk factors

Normal ageing and Alzheimer's disease (AD) have many features in common and, in many respects, both conditions only differ by quantitative criteria. A variety of genetic, medical and environmental factors modulate the ageing-related processes leading the brain into the devastation of AD. In accordance with the concept that AD is a metabolic disease, these risk factors deteriorate the homeostasis of the Ca(2+)-energy-redox triangle and disrupt the cerebral reserve capacity under metabolic stress. The major genetic risk factors (APP and presenilin mutations, Down's syndrome, apolipoprotein E4) are associated with a compromise of the homeostatic triangle. The pathophysiological processes leading to this vulnerability remain elusive at present, while mitochondrial mutations can be plausibly integrated into the metabolic scenario. The metabolic leitmotif is particularly evident with medical risk factors which are associated with an impaired cerebral perfusion, such as cerebrovascular diseases including stroke, cardiovascular diseases, hypo- and hypertension. Traumatic brain injury represents another example due to the persistent metabolic stress following the acute event. Thyroid diseases have detrimental sequela for cerebral metabolism as well. Furthermore, major depression and presumably chronic stress endanger susceptible brain areas mediated by a host of hormonal imbalances, particularly the HPA-axis dysregulation. Sociocultural and lifestyle factors like education, physical activity, diet and smoking may also modulate the individual risk affecting both reserve capacity and vulnerability. The pathophysiological relevance of trace metals, including aluminum and iron, is highly controversial; at any rate, they may adversely affect cellular defences, antioxidant competence in particular. The relative contribution of these factors, however, is as individual as the pattern of the factors. In familial AD, the genetic factors clearly drive the sequence of events. A strong interaction of fat metabolism and apoE polymorphism is suggested by intercultural epidemiological findings. In cultures, less plagued by the 'blessings' of the 'cafeteria diet-sedentary' Western lifestyle, apoE4 appears to be not a risk factor for AD. This intriguing evidence suggests that, analogous to cardiovascular diseases, apoE4 requires a hyperlipidaemic lifestyle to manifest as AD risk factor. Overall, the etiology of AD is a key paradigm for a gene-environment interaction. Copyright 2000 John Wiley & Sons, Ltd.

Neuroautoantibody immunoreactivity in relation to aging and stress in apolipoprotein E-deficient mice

Progressive disruption of both the neuroendocrine and immune systems has been correlated with age-associated pathogenesis in patients with Alzheimer's disease and in mice lacking apolipoprotein E (ApoE). In this study, we examined neuroautoimmune and neuroendocrine activities in relation to aging and stress in ApoE-deficient mice. An elevated level of autoantibodies against brain antigens was found in sera from ApoE-deficient mice compared to that of wild-type mice as early as 7-8 weeks of age. However, there was no significant difference between the two genotypes at this age in the effect of stress on serum corticosterone or autoantibody titers. Higher titers of autoantibodies were observed in approximately 12-week-old ApoE-deficient mice, especially in those exposed to chronic stress. Based on Western analysis, sera from ApoE-deficient mice showed a strong immunoreactivity with approximately 78 kDa and approximately 40 kDa brain abundant polypeptides, approximately 58 kDa non-brain tissue abundant antigen, and others of approximately, 80-82 kDa in both the brain and non-brain tissues. Immunofluorescence confocal microscopy showed that the major cellular components recognized by the autoimmune sera from ApoE-deficient mice were associated with neuronal cell nuclei and fiber-like structures in different regions of the brain, including the frontal cortex, lateral cortex and hippocampus. These results suggest that neuroautoimmunity associated with the aging process and exposure to chronic stress may be involved in early development of neurodegeneration in mice with ApoE-deficiency.

Apolipoprotein-E deficiency results in an altered stress responsiveness in addition to an impaired spatial memory in young mice

It has been suggested that Alzheimer's disease (AD) is associated with an altered neurotrophic function of apolipoprotein-E (ApoE) and abnormal neuroendocrine activities. In the present study we investigated stress responsiveness of ApoE-deficient mice. Firstly, two sessions of restraint were introduced, 20 min per day for two (session 1) and three (session 2) consecutive days. In session 1, there was no difference between genotypes in open-field activity in response to restraint stress. In session 2, spatial memory was assessed in a Morris Water Maze 'Place Learning Set' task immediately following stress. Restraint stress caused a significant impairment of spatial memory in wild-type mice. The non-restraint ApoE-deficient mice showed a severe impairment of spatial memory similar to that of the restrained wild-type mice. Restraint stress had no obvious effect on spatial memory in ApoE-deficient mice until the third day of testing, when there was a decrease in reference memory compared with their non-restraint controls. In addition, the first session of restraint stress had an inhibitory effect on food intake in wild-type but not ApoE-deficient mice, and a longer-lasting effect on body weight in the wild-type than ApoE-deficient mice. ApoE-deficient mice showed a weaker corticosterone response to the initial restraint stress and a slower descending rate in serum corticosterone level during a 30-min post-stress period than their wild-type controls. However, higher baseline levels and stronger corticosterone responses were observed in ApoE-deficient mice than in wild-type mice when exposed to repeated restraint stress. The expression of ApoE mRNA was upregulated in the hypothalamus in wild-type mice exposed to repeated restraint stress. Taken together, these results demonstrate that ApoE deficiency causes a memory impairment and an altered stress responsiveness in mice.

ApoE, Alzheimer's disease, and recovery from brain stress

Apolipoprotein E (APOE, gene; ApoE, protein) is the major genetic susceptibility locus for the common forms of Alzheimer's disease (AD). There are three common polymorphisms in the population: epsilon 2, epsilon 3, and epsilon 4. The inheritance of each dose of epsilon 4 increases the risk and lowers the age of onset distribution for AD; epsilon 2 lowers the risk and increases the age of onset distribution. APOE-epsilon 4 has a high positive predictive value for AD, and is clinically useful as an adjunct in the early diagnosis of cognitively impaired patients. The APOE alleles have also been associated with risk of AD with head injury, intraneuronal localization of ApoE in animal stroke models, recovery of function after intracerebral hemorrhage, and recovery of psychological parameters after general cardiac anesthesia. A multifunctional role of ApoE in the brain implicates isoform-specific differences in interactions with several brain proteins including A beta, tau, and MAP-2. Intraneuronal ApoE is increased temporally and in relevant neurons in AD as a function of APOE genotype. Decreased glucose metabolism can be demonstrated by PET imaging in subjects two decades before the median age of onset as a function of APOE genotype. ApoE isoforms may also have different effects as antioxidants. The risk of stroke and vascular dementia has not been confirmed in neuropathological series to be related to specific APOE genotypes.