Tau-induced focal neurotoxicity and network disruption related to apathy in Alzheimer's disease

Local and distant atrophy mediate the relationship between tau pathology and cognition in temporoparietal region in Alzheimer's disease

BackgroundTau pathology is closely associated with brain atrophy and cognitive decline, but how it specifically influences local and distant gray matter volume (GMV) and cognitive function remains unclear.ObjectiveThis study aims to explore the spatial relationships between tau pathology, GMV and cognition using hybrid positron emission tomography/magnetic resonance imaging (PET/MRI).MethodsTwenty amyloid-β (Aβ)-positive Alzheimer's disease (AD) patients, 14 mild cognitive impairment (MCI) patients, and 22 Aβ-negative normal controls (NC) underwent standardized neuropsychological assessments and 18F-fortaucipir PET/MRI scans. We investigated the associations between regional tau standardized uptake value ratio (SUVR) and GMV in AD signature regions. Mediation analyses were conducted to explore the potential mediating effects of local and distant GMV in the relationship between tau pathology and cognition.ResultsThe study indicated that increased 18F-fortaucipir SUVR and decreased GMV were related to cognitive performance in MCI and AD patients. Compared to NC group, the number of brain regions with local and distant correlations between GMV and SUVR was greater in AD/MCI group. Mediation analysis revealed that GMV served as a significant mediator between tau pathology and cognition in local regions. Furthermore, distant effects were also observed, with hippocampal atrophy partially mediated the relationship between entorhinal cortex tau pathology and cognition. Meanwhile, medial parietal lobe atrophy partially mediated the relationship between medial temporal lobe tau deposition and cognition.ConclusionsOur findings provide an anatomically detailed insight into relationships between tau, GMV and cognition, especially in entorhinal cortex-hippocampus, temporal-parietal lobe cortical circuits.

Correlation between changes in apathy and cognition in Alzheimer's disease associated apathy: Analysis of the Apathy in Dementia Methylphenidate Trial 2 (ADMET 2)

BACKGROUND

Previous trials have shown improvements in both apathy and cognition with methylphenidate (MPH).

OBJECTIVES

To assess whether changes in apathy correlated with changes in cognition in the Apathy in Dementia Methylphenidate Trial 2 (ADMET 2).

PARTICIPANTS

Mild to moderate AD patients with clinically significant apathy randomized to MPH (20 mg/day) or placebo for 6 months.

MEASUREMENTS

Apathy was measured with the Neuropsychiatric Inventory-apathy (NPI-A) domain. Cognition was measured using the Mini-Mental State Exam (MMSE), Hopkins Verbal Learning (immediate [HVLT-I], delayed [HVLT-D] recall), Digit Span (Forward [DF], Backward [DB]), Trail Making (TMT-A, TMT-B), Action Verbal Fluency (AV), Category Fluency (CF), and the Short Boston Naming Test (BNT).

DESIGN

Linear mixed models included cognitive change scores as dependent variables and time, treatment, change in NPI-A and the interaction between treatment and change in NPI-A as independent variables, which were additionally adjusted for baseline NPI-A and cognitive scores, age, sex, level of education and presence of diabetes.

RESULTS

199 participants (66 % male) were included (98-MPH, 101-placebo). Among all participants, worsening CF was associated with worsening apathy (-0.15 (0.05), p = .003). In addition, change in HVLT-I was associated with the interaction between changes in apathy and treatment (-0.31 (0.07), p = 0.0000158).

CONCLUSION

Changes in apathy are mostly independent of cognitive changes and apathy response to MPH may be independent from cognition. These results are consistent with the view that apathy as a syndrome is related to but distinct from cognition.

Advances in the study of apathy related to cerebral small vessel disease

Cerebral small vessel disease (CSVD) is a complex clinical-imaging pathological syndrome caused by small vessel lesions in the brain, which is characterized by aging-related, insidious onset and slow progression. Apathy is a key component of the common neuropsychiatric symptoms among CSVD patients, severely affecting their daily lives and social functioning. Moreover, there are fewer studies on CSVD-related apathy, and greater attention should be paid to this condition in clinical practice. This article describes the latest research advances in the concept, epidemiological features, pathogenesis, assessment and diagnosis, imaging and biomarkers, and treatment of CSVD-related apathy, aiming to serve as a reference for the clinical diagnosis and prevention of CSVD-related apathy.

Behavioral and psychological symptoms and brain volumes in community-dwelling older persons from the Nakayama Study

The frequency of behavioral and psychological symptoms of dementia (BPSD) is high, and it is a challenge to elucidate its neural substrates underlying their development. In recent years, many findings have been reported on the relationship between BPSD and brain volume in dementia patients. However, the results are not fully conclusive. Furthermore, there have been few population-based studies. Therefore, the relationship between BPSD and brain volume was investigated as an exploratory study. Of the 927 older persons who participated in the fifth Nakayama study, 90 were included in this analysis, consisting of 52 patients with mild cognitive impairment and 38 patients with dementia, with head MRI and the Neuropsychiatric Inventory (NPI) data. Multiple regression analysis was used to examine the association between the total score of each BPSD score on the NPI and brain volume estimated by FreeSurfer. On multivariate adjustment, even after false discovery rate correction, insular cortical volumes decreased significantly as total scores for apathy/indifference increased (p value = 0.002, q-value = 0.01). Similarly, total brain volume decreased significantly as total scores for appetite and eating disturbance increased (p value = 0.03), and parietal, temporal, and hippocampal cortical volumes also decreased significantly as total scores for appetite and eating disturbance increased (all p and q values < 0.05). This study's results suggest that apathy is negatively correlated with insular cortical volume, and that appetite and eating disturbance are also correlated with brain regions, including parietal, temporal, and hippocampal volume in a community-dwelling older population.

Effects of APOE ε4 and Neuropathological Diagnoses on Neuropsychiatric Symptoms: Mediation Analyses and Likely Causation in an Integrated National Alzheimer's Coordinating Center Database

BACKGROUND

In this study, we sought to identify paths from APOE ε4 to neurobehaviors itemized on a neuropsychiatric inventory (Neuropsychiatric Inventory-Questionnaire [NPI-Q]) that involved neuropathologies associated with APOE ε4 (amyloid, tau, cerebral amyloid angiopathy, and Lewy bodies) or cognition mediators (memory or global cognitive status) as well as direct paths from APOE ε4 to neurobehaviors.

METHODS

A total of 1199 cases with available neurobehavioral, cognition, and neuropathological data were included. We conducted a series of causal mediation analyses in which APOE ε4 always served as the independent variable, and NPI-Q neurobehavioral items, when included in the mediation analysis, served as the outcome. Neuropathologies or cognition served as mediators.

RESULTS

Multiple significant indirect paths from APOE ε4 through neuropathologies to neurobehaviors were identified. More refined analyses indicated that neuritic plaques and Braak stage drove the findings. A significant direct effect of APOE ε4 on memory was also identified. Additionally, Lewy body disease, when treated as an exposure, had a direct effect on hallucinations consistent with features of the disease.

CONCLUSIONS

We found strong evidence for partial mediation of NPI-Q symptoms by cognition, suggesting that cognitive limitations may have promoted maladaptive behavior. In addition, neuritic amyloid plaque levels and Braak stage, but not diffuse amyloid plaque extent, were key in NPI-Q-mediated associations, suggesting the possibility that synaptic failure plays an important role in multiple neurobehavioral symptoms in dementia, including psychosis. Finally, we found strong evidence that APOE ε4 may have direct effects on cognition when we used verbal episodic memory but not global cognitive status as an outcome.

Cerebrospinal fluid amyloid-β and cerebral microbleed are associated with distinct neuropsychiatric sub-syndromes in cognitively impaired patients

BACKGROUND

Neuropsychiatric symptoms (NPS) are prevalent in cognitively impaired individuals including Alzheimer's disease (AD) dementia and mild cognitive impairment (MCI). Whereas several studies have reported the associations between NPS with AD pathologic biomarkers and cerebral small vessel disease (SVD), but it remains unknown whether AD pathology and SVD contribute to different sub-syndromes independently or aggravate same symptoms synergistically.

METHOD

We included 445 cognitively impaired individuals (including 316 MCI and 129 AD) with neuropsychiatric, cerebrospinal fluid (CSF) biomarkers (Aβ42, p-tau, and t-tau) and multi-model MRI data. Psychiatric symptoms were accessed by using the Neuropsychiatric Inventory (NPI). Visual assessment of SVD (white matter hyperintensity, microbleed, perivascular space, lacune) on MRI images was performed by experienced radiologist. Linear regression analyses were conducted to test the association between neuropsychiatric symptoms with AD pathology and CSVD burden after adjustment for age, sex, education, apolipoprotein E (APOE) ε4 carrier status, and clinical diagnosis.

RESULTS

The NPI total scores were related to microbleed (estimate 2.424; 95% CI [0.749, 4.099]; P =0.005). Considering the sub-syndromes, the hyperactivity was associated with microbleed (estimate 0.925; 95% CI [0.115, 1.735]; P =0.025), whereas the affective symptoms were correlated to CSF level of Aβ42 (estimate -0.006; 95% CI [-0.011, -0.002]; P =0.005). Furthermore, we found the apathy sub-syndrome was associated with CSF t-tau/Aβ42 (estimate 0.636; 95% CI [0.078, 1.194]; P =0.041) and microbleed (estimate 0.693; 95% CI [0.046, 1.340]; P =0.036). In addition, we found a significant interactive effect between CSF t-tau/Aβ42 and microbleed (estimate 0.993; 95% CI [0.360, 1.626]; P =0.019) on severity of apathy sub-syndrome.

CONCLUSION

Our study showed that CSF Aβ42 was associated with affective symptoms, but microbleed was correlated with hyperactivity and apathy, suggesting the effect of AD pathology and SVD on different neuropsychiatric sub-syndromes.

Prevalence, treatment, and neural correlates of apathy in different forms of dementia: a narrative review

OBJECTIVES

The aim of this review is to provide an overview on prevalence and clinical tools for the diagnosis of apathy, as well as on neurophysiological and neuroimaging findings obtained from studies in patients with apathy in different forms of dementia, including Alzheimer's disease (AD), vascular (VaD) and mixed dementia, frontotemporal dementia (FTD), and Parkinson's disease dementia (PDD).

METHODS

Randomized controlled trials, non-randomized controlled trials, controlled before-after studies, and interrupted time series from four databases (WebOfScience, Scopus, Pubmed, and PsycINFO) addressing apathy in adults or older people aged over 65 years of age affected by dementia were included.

RESULTS

The prevalence of apathy was 26-82% for AD, 28.6-91.7 for VaD, 29-97.5% in PDD, and 54.8-88.0 in FTD. The assessment of apathy was not consistent in the reviewed studies. Methylphenidate was the most successful pharmacological treatment for apathy. Neurobiological studies highlighted the relationship between both structural and functional brain areas and the presence or severity of apathy.

CONCLUSION

Apathy is a very common disorder in all types of dementia, although it is often underdiagnosed and undertreated. Further studies are needed to investigate its diagnosis and management. A consensus on the different evaluation scales should be achieved.

Effects of APOE e4 and Neuropathological Diagnoses on Neuropsychiatric Symptoms: Mediation Analyses and Likely Causation in an Integrated NACC Database

Background

Our goal in this study was to identify paths from APOE e4 to neurobehaviors itemized on a neuropsychiatric inventory that involved neuropathologies associated with e4 (amyloid, tau, cerebral amyloid angiopathy, and Lewy bodies) or cognition mediators (memory or global cognitive status), as well as direct paths from e4 to cognition or neurobehaviors.

Methods

A total of 1199 cases with available neurobehavioral, cognition and neuropathological data were included. We then conducted a series of causal mediation analyses in R in which e4 always served as the independent variable and Neuropsychiatric Inventory (NPI) neurobehavioral items, when included in the mediation, the outcome. Neuropathologies or cognition served as mediators.

Results

Multiple significant indirect paths from e4 through neuropathologies to neurobehaviors were identified. More refined analyses indicated that neuritic plaques and Braak stage, but not extent of diffuse amyloid plaques, drove the findings. A significant direct effect of e4 to memory was also identified. Additionally, Lewy body disease, when treated as an exposure, had a direct effect on hallucinations in keeping with known features of the disease.

Conclusions

We found strong evidence for partial mediation of NPI symptoms by cognition, suggesting that cognitive limitations that may have influenced understanding (or misunderstanding) the environment with impacts on maladaptive behavior. In addition, neuritic amyloid plaque levels and Braak stage, but not diffuse amyloid plaque extent, were key in NPI mediated associations suggesting the possibility that synaptic failure play an important role in multiple neurobehavioral symptoms in dementia, including psychosis. Last, we found strong evidence that e4 may have direct effects on cognition when we used verbal episodic memory as an outcome, suggesting that medial temporal regions that support memory may be sensitive to non-amyloidogenic and non-tau related pathophysiological processes.

Characterization of apathy-like behaviors in the 5xFAD mouse model of Alzheimer's disease

Most patients with Alzheimer's disease (AD) develop neuropsychiatric symptoms (NPS) alongside cognitive decline, and apathy is one of the most common symptoms. Few preclinical studies have investigated the biological substrates underlying NPS in AD. In this study, we used a cross-sectional design to characterize apathy-like behaviors and assess memory in 5xFAD and wildtype control mice at 6, 12, and 16 months of age. Nest building, burrowing, and marble burying were used to test representative behaviors of apathy, and a composite score of apathy-like behavior was generated from these assays. Soluble Aβ42 and plaques were quantified in the prefrontal cortex and hippocampus of the 5xFAD mice with the highest and lowest composite scores using ELISA and histology. Results suggest that 5xFAD mice develop significant apathy-like behaviors starting at 6 months of age that worsen with aging and are positively correlated with soluble Aβ42 and plaques in the prefrontal cortex and hippocampus. Our findings highlight the utility of studying NPS in mouse models of AD to uncover important relationships with underlying neuropathology.

The cytoplasmic localization of ADNP through 14-3-3 promotes sex-dependent neuronal morphogenesis, cortical connectivity, and calcium signaling

Defective neuritogenesis is a contributing pathogenic mechanism underlying a variety of neurodevelopmental disorders. Single gene mutations in activity-dependent neuroprotective protein (ADNP) are the most frequent among autism spectrum disorders (ASDs) leading to the ADNP syndrome. Previous studies showed that during neuritogenesis, Adnp localizes to the cytoplasm/neurites, and Adnp knockdown inhibits neuritogenesis in culture. Here, we hypothesized that Adnp is localized in the cytoplasm during neurite formation and that this process is mediated by 14-3-3. Indeed, applying the 14-3-3 inhibitor, difopein, blocked Adnp cytoplasmic localization. Furthermore, co-immunoprecipitations showed that Adnp bound 14-3-3 proteins and proteomic analysis identified several potential phosphorylation-dependent Adnp/14-3-3 binding sites. We further discovered that knockdown of Adnp using in utero electroporation of mouse layer 2/3 pyramidal neurons in the somatosensory cortex led to previously unreported changes in neurite formation beginning at P0. Defects were sustained throughout development, the most notable included increased basal dendrite number and axon length. Paralleling the observed morphological aberrations, ex vivo calcium imaging revealed that Adnp deficient neurons had greater and more frequent spontaneous calcium influx in female mice. GRAPHIC, a novel synaptic tracing technology substantiated this finding, revealing increased interhemispheric connectivity between female Adnp deficient layer 2/3 pyramidal neurons. We conclude that Adnp is localized to the cytoplasm by 14-3-3 proteins, where it regulates neurite formation, maturation, and functional cortical connectivity significantly building on our current understanding of Adnp function and the etiology of ADNP syndrome.

Apathy in Alzheimer's disease: A neurocircuitry based perspective

In addition to memory deficits and other cognitive disturbances, patients with Alzheimer's disease (AD) experience neuropsychiatric symptoms, notably apathy, which is a state of impaired motivation observed by deficits in goal directed behavior. Apathy is a multifaceted neuropsychiatric condition and appears to be a prognostic indicator, correlating with the progression of AD. Strikingly, recent studies point out that the neurodegenerative pathology of AD may drive apathy independent of cognitive decline. These studies also highlight that neuropsychiatric symptoms, in particular apathy, might manifest early in AD. Here, we review the current understanding of the neurobiological underpinnings of apathy as a neuropsychiatric symptom of AD. Specifically, we highlight the neural circuits and brain regions recognized to be correlated with the apathetic symptomatology. We also discuss the current evidence that supports the notion that apathy and cognitive deficits may develop as independent but concurrent phenomena driven by AD pathology, suggesting its efficacy as an additional outcome measure in Alzheimer's disease clinical trials. The current and prospective therapeutic interventions for apathy in AD from a neurocircuitry based perspective are also reviewed.

The Sensitivity of Tau Tracers for the Discrimination of Alzheimer's Disease Patients and Healthy Controls by PET

Hyperphosphorylated tau aggregates, also known as neurofibrillary tangles, are a hallmark neuropathological feature of Alzheimer's disease (AD). Molecular imaging of tau by positron emission tomography (PET) began with the development of [18F]FDDNP, an amyloid β tracer with off-target binding to tau, which obtained regional specificity through the differing distributions of amyloid β and tau in AD brains. A concerted search for more selective and affine tau PET tracers yielded compounds belonging to at least eight structural categories; 18F-flortaucipir, known variously as [18F]-T807, AV-1451, and Tauvid®, emerged as the first tau tracer approved by the American Food and Drug Administration. The various tau tracers differ concerning their selectivity over amyloid β, off-target binding at sites such as monoamine oxidase and neuromelanin, and degree of uptake in white matter. While there have been many reviews of molecular imaging of tau in AD and other conditions, there has been no systematic comparison of the fitness of the various tracers for discriminating between AD patient and healthy control (HC) groups. In this narrative review, we endeavored to compare the binding properties of the various tau tracers in vitro and the effect size (Cohen's d) for the contrast by PET between AD patients and age-matched HC groups. The available tracers all gave good discrimination, with Cohen's d generally in the range of two-three in culprit brain regions. Overall, Cohen's d was higher for AD patient groups with more severe illness. Second-generation tracers, while superior concerning off-target binding, do not have conspicuously higher sensitivity for the discrimination of AD and HC groups. We suppose that available pharmacophores may have converged on a maximal affinity for tau fibrils, which may limit the specific signal imparted in PET studies.

Two pathways differentially linking tau depositions, oxidative stress, and neuronal loss to apathetic phenotypes in progressive supranuclear palsy

Patients with progressive supranuclear palsy (PSP) frequently exhibit apathy but the neuropathological processes leading to this phenotype remain elusive. We aimed to examine the involvement of tau protein depositions, oxidative stress (OS), and neuronal loss in the apathetic manifestation of PSP. Twenty patients with PSP and twenty-three healthy controls were enrolled. Tau depositions and brain volumes were evaluated via positron-emission tomography (PET) using a specific probe, ¹⁸F-PM-PBB3, and magnetic resonance imaging, respectively. Glutathione (GSH) levels in the anterior and posterior cingulate cortices were quantified by magnetic resonance spectroscopy. Tau pathologies were observed in the subcortical and cortical structures of the patient brains. The angular gyrus exhibited a positive correlation between tau accumulations and apathy scale (AS). Although PSP cases did not show GSH level alterations compared with healthy controls, GSH levels in posterior cingulate cortex were correlated with AS and tau depositions in the angular gyrus. Marked atrophy was observed in subcortical areas, and gray matter volumes in the inferior frontal gyrus and anterior cingulate cortex were positively correlated with AS but showed no correlation with tau depositions and GSH levels. Path analysis highlighted synergistic contributions of tau pathologies and GSH reductions in the posterior cortex to AS, in parallel with associations of gray matter atrophy in the anterior cortex with AS. Apathetic phenotypes may arise from PET-visible tau aggregation and OS compromising the neural circuit resilience in the posterior cortex, along with neuronal loss, with neither PET-detectable tau pathologies nor OS in the anterior cortex.

The neurobiology of apathy in depression and neurocognitive impairment in older adults: a review of epidemiological, clinical, neuropsychological and biological research

Apathy is a common condition that involves diminished initiative, diminished interest and diminished emotional expression or responsiveness. It is highly prevalent in the context of a variety of neuropsychiatric disorders and is related to poor health outcomes. Presence of apathy is associated with cognitive and functional decline in dementia. Despite its negative impact on health, there is no definitive treatment for apathy, a clinical reality that may be due in part to lack of knowledge about assessment, neuropsychological features and neurobiological underpinnings. Here, we review and synthesize evidence from clinical, epidemiological, neuropsychological, peripheral biomarker and neuroimaging research. Apathy is a common feature of depression and cognitive disorders and is associated with impairment in executive function. Neuropsychological and neuroimaging studies point to dysfunction of brain circuitry involving the prefrontal cortex, especially the dorsolateral prefrontal cortex circuit, the dorsomedial prefrontal cortex circuit, and the ventromedial prefrontal cortex circuit. However, inconsistent findings, particularly in neuroimaging may be due to heterogeneity of apathy symptoms (with a need to better elucidate subtypes), neuropsychiatric comorbidities, the severity of cognitive impairment and other factors. These factors need to be accounted for in future studies so that biomarker research can make progress. On the whole, the literature on apathy has identified likely neurocognitive, peripheral biomarker and neuroimaging targets for understanding apathy, but also points to the need to address methodological issues that will better inform future studies. In turn, as we learn more about the underpinning of apathy and its subtypes, subsequent research can focus on new neurally based interventions that will strengthen the clinical management of apathy in the context of its comorbidities.

Mediation Analyses of the Role of Apathy on Motoric Cognitive Outcomes

Recent literature indicates that apathy is associated with poor cognitive and functional outcomes in older adults, including motoric cognitive risk syndrome (MCR), a predementia syndrome. However, the underlying biological pathway is unknown. The objectives of this study were to (1) examine the cross-sectional associations between inflammatory cytokines (Interleukin 6 (IL-6) and C-Reactive Protein (CRP)) and apathy and (2) explore the direct and indirect relationships of apathy and motoric cognitive outcomes as it relates to important cognitive risk factors. N = 347 older adults (≥65 years old) enrolled in the Central Control of Mobility in Aging Study (CCMA). Linear and logic regression models showed that IL-6, but not CRP was significantly associated with apathy adjusted for age, gender, and years of education (β = 0.037, 95% CI: 0.002-0.072, p = 0.04). Apathy was associated with a slower gait velocity (β = -14.45, 95% CI: -24.89-4.01, p = 0.01). Mediation analyses demonstrated that IL-6 modestly mediates the relationship between apathy and gait velocity, while apathy mediated the relationships between dysphoria and multimorbidity and gait velocity. Overall, our findings indicate that apathy may be an early predictor of motoric cognitive decline. Inflammation plays a modest role, but the underlying biology of apathy warrants further investigation.

PET-based classification of corticobasal syndrome

INTRODUCTION

Corticobasal degeneration (CBD) is the most common neuropathological substrate for clinically diagnosed corticobasal syndrome (CBS), while identifying CBD pathology in living individuals has been challenging. This study aimed to examine the capability of positron emission tomography (PET) to detect CBD-type tau depositions and neuropathological classification of CBS.

METHODS

Sixteen CBS cases diagnosed by Cambridge's criteria and 12 cognitively healthy controls (HCs) underwent PET scans with ¹¹C-PiB, ¹¹C-PBB3, and ¹⁸F-FDG, along with T1-weighted magnetic resonance imaging. Amyloid positivity was assessed by visual inspection of ¹¹C-PiB retentions. Tau positivity was judged by quantitative comparisons of ¹¹C-PBB3 binding to HCs.

RESULTS

Sixteen CBS cases consisted of two cases (13%) with amyloid and tau positivities indicative of Alzheimer's disease (AD) pathologies, 11 cases (69%) with amyloid negativity and tau positivity, and three cases (19%) with amyloid and tau negativities. Amyloid(-), tau(+) CBS cases showed increased retentions of ¹¹C-PBB3 in the frontoparietal areas, basal ganglia, and midbrain, and reduced metabolism in the precentral gyrus and thalamus relative to HCs. The enhanced tau probe retentions in the frontal gray and white matters partially overlapped with metabolic deficits and atrophy and correlated with Clinical Dementia Rating scores.

CONCLUSIONS

PET-based classification of CBS was in accordance with previous neuropathological reports on the prevalences of AD, non-AD tauopathies, and others in CBS. The current work suggests that ¹¹C-PBB3-PET may assist the biological classification of CBS and understanding of links between CBD-type tau depositions and neuronal deteriorations leading to cognitive declines.

Cerebral Volumetric Correlates of Apathy in Alzheimer's Disease and Cognitively Normal Older Adults: Meta-Analysis, Label-Based Review, and Study of an Independent Cohort

BACKGROUND

Affecting nearly half of the patients with Alzheimer's disease (AD), apathy is associated with higher morbidity and reduced quality of life. Basal ganglia and cortical atrophy have been implicated in apathy. However, the findings have varied across studies and left unclear whether subdomains of apathy may involve distinct neuroanatomical correlates.

OBJECTIVE

To identify neuroanatomical correlates of AD-associated apathy.

METHODS

We performed a meta-analysis and label-based review of the literature. Further, following published routines of voxel-based morphometry, we aimed to confirm the findings in an independent cohort of 19 patients with AD/mild cognitive impairment and 25 healthy controls assessed with the Apathy Evaluation Scale.

RESULTS

Meta-analysis of 167 AD and 56 healthy controls showed convergence toward smaller basal ganglia gray matter volume (GMV) in apathy. Label-based review showed anterior cingulate, putamen, insula, inferior frontal gyrus (IFG) and middle temporal gyrus (MTG) atrophy in AD apathy. In the independent cohort, with small-volume-correction, right putamen and MTG showed GMVs in negative correlation with Apathy Evaluation Scale total, behavioral, and emotional scores, and right IFG with emotional score (p < 0.05 family-wise error (FWE)-corrected), controlling for age, education, intracranial volume, and depression. With the Mini-Mental State Examination scores included as an additional covariate, the correlation of right putamen GMV with behavioral and emotional score, right MTG GMV with total and emotional score, and right IFG GMV with emotional score were significant.

CONCLUSION

The findings implicate putamen, MTG and IFG atrophy in AD associated apathy, potentially independent of cognitive impairment and depression, and suggest potentially distinct volumetric correlates of apathy.

Apathetic symptoms and white matter integrity after traumatic brain injury

PRIMARY OBJECTIVE

The aim of the study was twofold. First, to study the relationship among apathy in the long term, initial clinical measures, and standard outcome scores after traumatic brain injury (TBI). Second, to describe white matter integrity correlates of apathy symptoms.

RESEARCH DESIGN

Correlational study. Methods and Procedures: Correlation and Bayesian networks analyses were performed in a sample of 40 patients with moderate to severe TBI in order to identify the relationship among clinical variables, functionality, and apathy. A diffusion tensor imaging study was developed in 25 participants to describe correlations between fractional anisotropy (FA) measures and apathetic symptoms.

MAIN OUTCOMES AND RESULTS

Correlation analysis revealed associations between pairs of variables as apathy in the long term and functional score at discharge from hospital. Bayesian network illustrated the relevant role of axonal injury mediating the relationship between apathy and initial clinical variables. FA in the superior longitudinal fasciculus, the inferior longitudinal fasciculus, and the internal capsule were negatively correlated with apathy measures. Widespread brain areas showed positive correlations between FA and apathy.

CONCLUSIONS

These results highlight the relevance of white matter integrity measures in initial assessment after TBI and its relationship with apathetic manifestations in the chronic phase.

Parametric Estimation of Reference Signal Intensity for Semi-Quantification of Tau Deposition: A Flortaucipir and [18F]-APN-1607 Study

BACKGROUND

Tau positron emission tomography (PET) imaging can reveal the pathophysiology and neurodegeneration that occurs in Alzheimer's disease (AD) in vivo. The standardized uptake value ratio (SUVR) is widely used for semi-quantification of tau deposition but is susceptible to disturbance from the reference region and the partial volume effect (PVE). To overcome this problem, we applied the parametric estimation of reference signal intensity (PERSI) method-which was previously evaluated for flortaucipir imaging-to two tau tracers, flortaucipir and [18F]-APN-1607.

METHODS

Two cohorts underwent tau PET scanning. Flortaucipir PET imaging data for cohort I (65 healthy controls [HCs], 60 patients with mild cognitive impairment [MCI], and 12 AD patients) were from the AD Neuroimaging Initiative database. [18F]-APN-1607 ([18F]-PM-PBB3) PET imaging data were for Cohort II, which included 21 patients with a clinical diagnosis of amyloid PET-positive AD and 15 HCs recruited at Huashan Hospital. We used white matter (WM) postprocessed by PERSI (PERSI-WM) as the reference region and compared this with the traditional semi-quantification method that uses the whole cerebellum as the reference. SUVRs were calculated for regions of interest including the frontal, parietal, temporal, and occipital lobes; anterior and posterior cingulate; precuneus; and Braak I/II (entorhinal cortex and hippocampus). Receiver operating characteristic (ROC) curve analysis and effect sizes were used to compare the two methods in terms of ability to discriminate between different clinical groups.

RESULTS

In both cohorts, regional SUVR determined using the PERSI-WM method was superior to using the cerebellum as reference region for measuring tau retention in AD patients (e.g., SUVR of the temporal lobe: flortaucipir, 1.08 ± 0.17 and [18F]-APN-1607, 1.57 ± 0.34); and estimates of the effect size and areas under the ROC curve (AUC) indicated that it also increased between-group differences (e.g., AUC of the temporal lobe for HC vs AD: flortaucipir, 0.893 and [18F]-APN-1607: 0.949).

CONCLUSION

The PERSI-WM method significantly improves diagnostic discrimination compared to conventional approach of using the cerebellum as a reference region and can mitigate the PVE; it can thus enhance the efficacy of semi-quantification of multiple tau tracers in PET scanning, making it suitable for large-scale clinical application.

Diagnostic criteria for apathy in neurocognitive disorders

INTRODUCTION

Apathy is common in neurocognitive disorders (NCD) but NCD-specific diagnostic criteria are needed.

METHODS

The International Society for CNS Clinical Trials Methodology Apathy Work Group convened an expert group and sought input from academia, health-care, industry, and regulatory bodies. A modified Delphi methodology was followed, and included an extensive literature review, two surveys, and two meetings at international conferences, culminating in a consensus meeting in 2019.

RESULTS

The final criteria reached consensus with more than 80% agreement on all parts and included: limited to people with NCD; symptoms persistent or frequently recurrent over at least 4 weeks, a change from the patient's usual behavior, and including one of the following: diminished initiative, diminished interest, or diminished emotional expression/responsiveness; causing significant functional impairment and not exclusively explained by other etiologies.

DISCUSSION

These criteria provide a framework for defining apathy as a unique clinical construct in NCD for diagnosis and further research.

Structural Brain Differences Between Cognitively Impaired Patients With and Without Apathy

OBJECTIVE

Since apathy increases in prevalence with severity of dementia pathology, we sought to distinguish concomitant neurodegenerative processes from brain differences associated with apathy in persons with mild cognitive impairment (MCI) and Alzheimer's Disease (AD). We examined relative structural brain differences between case-control matched cognitively impaired patients with and without apathy.

DESIGN

Cross-sectional case-control study.

SETTING

Fifty-eight clinical sites in phase 2 of the AD Neuroimaging Initiative across the United States and Canada.

PARTICIPANTS

The ≥ 55 years of age with MCI or AD dementia and no major neurological disorders aside from suspected incipient AD dementia. Participants with apathy (n=69) were age-, sex-, apolipoprotein E ε4 allele carrier status-, Mini-Mental State Exam score-, and MCI or AD dementia diagnosis-matched to participants without apathy (n=149).

INTERVENTIONS

The 3-tesla T1-weighted MRI scan and neurocognitive assessments. Using the Neuropsychiatric Inventory apathy domain scores, participants were dichotomized into a with-apathy group (score ≥ 1) and a without-apathy group (score = 0).

MEASUREMENTS

Cortical thicknesses from 24 a priori regions of interest involved in frontostriatal circuits and frontotemporal association areas.

RESULTS

False-discovery rate adjusted within-group comparisons between participants with apathy and participants without apathy showed thinner right medial orbitofrontal (mOFC; meandifference(MD)±standarderrorofMD(SE)=-0.0879±0.0257mm; standardizedMD(d)=-0.4456) and left rostral anterior cingulate (rACC; MD±SE=-0.0905±0.0325mm; d=-0.3574) cortices and thicker left middle temporal cortices (MTC; MD±SE=0.0688±0.0239mm; d=0.3311) in those with apathy.

CONCLUSION

Atrophy of the right mOFC and left rACC and sparing of atrophy in the left MTC are associated with apathy in cognitively impaired persons.

Bridging Scales in Alzheimer's Disease: Biological Framework for Brain Simulation With The Virtual Brain

Despite the acceleration of knowledge and data accumulation in neuroscience over the last years, the highly prevalent neurodegenerative disease of AD remains a growing problem. Alzheimer's Disease (AD) is the most common cause of dementia and represents the most prevalent neurodegenerative disease. For AD, disease-modifying treatments are presently lacking, and the understanding of disease mechanisms continues to be incomplete. In the present review, we discuss candidate contributing factors leading to AD, and evaluate novel computational brain simulation methods to further disentangle their potential roles. We first present an overview of existing computational models for AD that aim to provide a mechanistic understanding of the disease. Next, we outline the potential to link molecular aspects of neurodegeneration in AD with large-scale brain network modeling using The Virtual Brain (www.thevirtualbrain.org), an open-source, multiscale, whole-brain simulation neuroinformatics platform. Finally, we discuss how this methodological approach may contribute to the understanding, improved diagnostics, and treatment optimization of AD.

Radiosynthesis and quality control testing of the tau imaging positron emission tomography tracer [18 F]PM-PBB3 for clinical applications

Recently, we produced 11 C-labeled 2-((1E,3E)-4-(6-(methylamino)pyridin-3-yl)buta-1,3-dienyl)benzo[d]thiazol-6-ol ([11 C]PBB3) as a clinically useful positron emission tomography (PET) tracer for in vivo imaging of tau pathologies in the human brain. To overcome the limitations (i.e., rapid in vivo metabolism and short half-life) of [11 C]PBB3, we further synthesized 18 F-labeled 1-fluoro-3-((2-((1E,3E)-4-(6-(methylamino)pyridine-3-yl)buta-1,3-dien-1-yl)benzo[d]thiazol-6-yl)oxy)propan-2-ol ([18 F]PM-PBB3). [18 F]PM-PBB3 is also a useful tau PET tracer for imaging tau pathologies. In this study, we developed a routine radiosynthesis and quality control testing of [18 F]PM-PBB3 for clinical applications. [18 F]PM-PBB3 was synthesized by direct 18 F-fluorination of the tosylated derivative, followed by removal of the protecting group. [18 F]PM-PBB3 was obtained with sufficient radioactivity (25 ± 6.0% of the nondecay-corrected radiochemical yield at the end of synthesis, EOS), radiochemical purity (98 ± 0.6%), and molar activity (350 ± 94 GBq/μmol at EOS; n = 53). Moreover, [18 F]PM-PBB3 consistently retained >95% of radiochemical purity for 60 min without undergoing photoisomerization using a new UV-cutoff light (yellow light) fixed in the hot cell to monitor the synthesis. All the results of the quality control testing for the [18 F]PM-PBB3 injection complied with our in-house quality control and quality assurance specifications. We have accomplished >200 production runs of [18 F]PM-PBB3 in our facility for various research purposes.

Widespread white matter aberration is associated with the severity of apathy in amnestic Mild Cognitive Impairment: Tract-based spatial statistics analysis

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In aMCI, apathy severity was associated with lower FA in widespread WM pathways.

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WM aberrations are related to apathy severity after controlling for depression.

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Disruptions related to apathy severity are not limited to frontal-subcortical area.

Apathy is recognized as a prevalent behavioral symptom of amnestic Mild Cognitive Impairment (aMCI). In aMCI, apathy is associated with an increased risk and increases the risk of progression to Alzheimer’s Disease (AD). Previous DTI study in aMCI showed that apathy has been associated with white matter alterations in the cingulum, middle and inferior longitudinal fasciculus, fornix, and uncinate fasciculus. However, the underlying white matter correlates associated with apathy in aMCI are still unclear. We investigated this relationship using whole-brain diffusion tensor imaging (DTI). Twenty-nine aMCI patients and 20 matched cognitively healthy controls were included. Apathy severity was assessed using the Apathy Evaluation Scale Clinician version. We applied the tract-based spatial statistics analyses to DTI parameters: fractional anisotropy (FA), mean diffusivity, axial diffusivity, and radial diffusivity to investigate changes in white matter pathways associated with the severity of apathy. No significant difference was found in any of the DTI parameters between aMCI and the control group. In aMCI, higher severity of apathy was associated with lower FA in various white matter pathways including the left anterior part of inferior fronto-occipital fasciculus/uncinate fasciculus, genu and body of the corpus callosum, superior and anterior corona radiata, anterior thalamic radiation of both hemispheres and in the right superior longitudinal fasciculus/anterior segment of arcuate fasciculus (p < .05, TFCE-corrected) after controlling for age, gender and GDS non-apathy. A trend association was observed in the right posterior corona radiata and corticospinal tract/internal capsule, and bilateral forceps minor (p < .065, TFCE-corrected). In conclusion, in aMCI, severity of apathy is associated with aberrant white matter integrity in widely distributed pathways, within and between hemispheres.

Neurobiologic Rationale for Treatment of Apathy in Alzheimer's Disease With Methylphenidate

The public health burden of Alzheimer's disease (AD) is related not only to cognitive symptoms, but also to neuropsychiatric symptoms, including apathy. Apathy is defined as a quantitative reduction of goal-directed activity in comparison to a previous level of functioning and affects 30%-70% of persons with AD. Previous attempts to treat apathy in AD-both nonpharmacologically and pharmacologically-have been wanting. Catecholaminergic treatment with methylphenidate has shown encouraging results in initial trials of apathy in AD. Understanding the neuronal circuits underlying motivated behavior and their reliance on catecholamine actions helps provide a rationale for methylphenidate actions in the treatment of apathy in patients with AD. Anatomical, physiological, and behavioral studies have identified parallel, cortical-basal ganglia circuits that govern action, cognition, and emotion and play key roles in motivated behavior. Understanding the distinct contributions to motivated behavior of subregions of the prefrontal cortex-dorsolateral, orbital-ventromedial, and dorsomedial-helps to explain why degeneration of these areas in AD results in apathetic behaviors. We propose that the degeneration of the prefrontal cortex in AD produces symptoms of apathy. We further propose that methylphenidate treatment may ameliorate those symptoms by boosting norepinephrine and dopamine actions in prefrontal-striatal-thalamocortical circuits.

Neuroanatomical Abnormalities in Older Depressed Adults With Apathy: A Systematic Review

OBJECTIVE

Apathy is a common phenomenon in late-life depression and is associated with poor outcomes. Apathy is often unrecognized in older depressed adults, and efficacious treatment options are lacking. This review provides a systematic review of the neuroanatomical abnormalities associated with apathy in late-life depression. In addition, the review summarizes the neuroimaging findings from studies of neurodegenerative and focal brain injury conditions that frequently present with apathy. The goal is to elucidate cerebral network abnormalities that give rise to apathy in older adults with mood disturbances and to inform future treatment targets.

METHOD

Systematic literature review.

RESULTS

The few studies that have directly examined the neuroanatomical abnormalities of apathy in late-life depression suggest disturbances in the anterior cingulate cortex, insula, orbital and dorsal prefrontal cortex, striatum, and limbic structures (ie, amygdala, thalamus, and hippocampus). Studies examining the neuroanatomical correlates of apathy in other aging populations are consistent with the pattern observed in late-life depression.

CONCLUSIONS

Apathy in late-life depression appears to be accompanied by neuroanatomical abnormalities in the salience and reward networks. These network findings are consistent with that observed in individuals presenting with apathy in other aging-related conditions. These findings may inform future treatments that target apathy.

Associations of [18F]-APN-1607 Tau PET Binding in the Brain of Alzheimer's Disease Patients With Cognition and Glucose Metabolism

Molecular imaging of tauopathies is complicated by the differing specificities and off-target binding properties of available radioligands for positron emission tomography (PET). [18F]-APN-1607 ([18F]-PM-PBB3) is a newly developed PET tracer with promising properties for tau imaging. We aimed to characterize the cerebral binding of [18F]-APN-1607 in Alzheimer's disease (AD) patients compared to normal control (NC) subjects. Therefore, we obtained static late frame PET recordings with [18F]-APN-1607 and [18F]-FDG in patients with a clinical diagnosis of AD group, along with an age-matched NC group ([18F]-APN-1607 only). Using statistical parametric mapping (SPM) and volume of interest (VOI) analyses of the reference region normalized standardized uptake value ratio maps, we then tested for group differences and relationships between both PET biomarkers, as well as their associations with clinical general cognition. In the AD group, [18F]-APN-1607 binding was elevated in widespread cortical regions (P < 0.001 for VOI analysis, familywise error-corrected P < 0.01 for SPM analysis). The regional uptake in AD patients correlated negatively with Mini-Mental State Examination score (frontal lobe: R = -0.632, P = 0.004; temporal lobe: R = -0.593, P = 0.008; parietal lobe: R = -0.552, P = 0.014; insula: R = -0.650, P = 0.003; cingulum: R = -0.665, P = 0.002) except occipital lobe (R = -0.417, P = 0.076). The hypometabolism to [18F]-FDG PET in AD patients also showed negative correlations with regional [18F]-APN-1607 binding in some signature areas of AD (temporal lobe: R = -0.530, P = 0.020; parietal lobe: R = -0.637, P = 0.003; occipital lobe: R = -0.567, P = 0.011). In conclusion, our results suggested that [18F]-APN-1607 PET sensitively detected tau deposition in AD and that individual tauopathy correlated with impaired cerebral glucose metabolism and cognitive function.

Relationship between Performance on the Mini-Mental State Examination Sub-Items and Activities of Daily Living in Patients with Alzheimer's Disease

Mini-mental state examination (MMSE) subitems provide useful information about the cognitive status of patients with Alzheimer's disease (AD). If the relationship between MMSE subitems and activities of daily living (ADL) can be shown, the performance of sub-items can predict ADL status and may provide useful information for early ADL intervention. Therefore, the purpose of this study was to investigate the relationship between MMSE subitem scores and ADL. The study sample consisted of 718 patients with AD. Logistic regression analysis using the Physical Self-maintenance Scale (PSMS) and Lawton's Instrumental ADL (L-IADL) was performed with each of the subitems as the dependent variables and the MMSE subitem as the independent variable. As a result, the subitems of MMSE, which are strongly related to each item in PSMS differed (e.g., toilet: registration odds ratio 3.00, grooming: naming 3.66). In the case of L-IADL, most items were strongly associated with "writing" (e.g., shopping: odds ratio 4.29, laundry 3.83). In clinical practice, we often focus only on the total MMSE score in patients with AD. However, the relationship between each MMSE subitem and ADL suggested in this study may be useful information that can be linked to ADL care from the performance of the MMSE subitem.

Tau Accumulation and Network Breakdown in Alzheimer's Disease

Misfolded and aggregated tau and amyloid β (Aβ) proteins are the pathological hallmarks of Alzheimer's disease (AD). These aberrant proteins lose their physiological roles, acquire neurotoxicity, and propagate across neural systems. Despite the growing understanding of the molecular pathophysiology, the relationship among molecular alterations, pathological changes, and dementia onset and progression remain to be elucidated. Connectivity is an exclusive characteristic of the brain, and the integrity and segregation of the functional and anatomical networks are crucial for normal functioning. Interestingly, a lot of magnetic resonance imaging (MRI) studies have demonstrated successive structural and functional disconnection among brain regions supporting the idea that AD is a disconnection syndrome. Recent several studies using the combination of cutting-edge Aβ and tau PET tracers integrated by data-driven statistical methods, resting-state functional MRI, and diffusion tensor imaging have shed light on the spatial distribution pattern of tau retention as well the relationship between tau retention and functional/structural network disruption in AD. Regional retention of tau PET traces is associated with gray matter changes, structural network disruption, and cognitive function tests. The tau retention will mainly spread along with cognition-related resting state networks and be more common in the network hubs which exhibit many strong interconnections with other regions within the network as well as without the networks. Mainly, precuneus and posterior cingulate gyrus are commonly involved and can be the critical nodes associated with clinically manifested dementia from the normal cognitive state.