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1.  Neuropathology in the Adult Changes in Thought Study: A Review 
The neuropathology underlying dementia syndromes in older populations is complex. The contributions of Alzheimer’s and Lewy body pathology are well appreciated. Recent studies with brain autopsies have highlighted the high prevalence of vascular disease as an independent, but often co-morbid contributor to dementia. The Adult Changes in Thought Study is a community-based, longitudinal study of brain aging and cognitive decline which has recently confirmed cerebral microinfarcts as a strong correlate of cognitive impairment and dementia. This study examines correlations between clinical characteristics including extensive, longitudinal medication histories, and longitudinal cognitive testing against structural and biochemical features of disease. Keywords: Aging, community-based, microinfarct, longitudinal, neuropathology.
doi:10.3233/JAD-2009-1180
PMCID: PMC4008877  PMID: 19661627
Aging; community-based; microinfarct; longitudinal; neuropathology
2.  Neuropathologic correlates of cognition in a population-based sample 
Many cognitively normal older adults have underlying neuropathologic changes of Alzheimer’s disease (AD), vascular brain injury (VBI), or Lewy body disease (LBD), which confer an increased risk of dementia. The current study focused on the association between multiple neuropathologic indices and performance on specific cognitive domains in a community sample of older adults. Of 438 participants in the Adult Changes in Thought population-based study of brain aging who were autopsied, 363 subjects had cognitive testing at their final study visit and were included. Associations were measured between performance on the Cognitive Abilities Screening Instrument prior to death and neuropathologic endpoints, including AD neuropathologic changes, LBD, cerebral amyloid angiopathy, and measures of VBI. Braak stage for neurofibrillary tangles, lower brain weight, and VBI as measured by cerebral cortical microvascular lesions (μVBI) explained a significant proportion of the variance associated with global cognitive test performance (R2=0.31, p< 0.0001) both in the entire sample and when analysis was restricted to non-demented subjects (R2= 0.23, p< 0.0001). Specific cognitive domains were differentially related to neuropathologic lesion type: memory and executive function with AD pathologic changes and cortical μVBI, executive function with subcortical μVBI, and visuospatial construction with LBD. Thus, neuropathologic lesions of LBD and μVBI are associated with poorer cognitive performance over and above AD neuropathologic changes in subjects without dementia in this cohort. These findings underscore that cognitive impairment is a complex convergent trait that has important implications for clinical investigation and medical management of older adults.
doi:10.3233/JAD-130281
PMCID: PMC3737376  PMID: 23666176
Alzheimer’s disease; brain; cerebrovascular disorders; cognition; dementia; Lewy bodies; pathologic processes
3.  Novel antibody capture assay for paraffin-embedded tissue detects wide-ranging amyloid beta and paired helical filament–tau accumulation in cognitively normal older adults 
Quantifying antigens in formalin-fixed tissue is challenging and limits investigation in population-based studies of brain aging. To address this major limitation, we have developed a new technique that we call “Histelide”: immunohistochemistry (HIST-) and ELISA (-EL-) performed on a glass slide (-IDE). We validated Histelide in sections of prefrontal cortex from 20 selected cases: 12 subjects with clinically and neuropathologically diagnosed Alzheimer’s disease (AD), either autosomal dominant or late-onset forms, and 8 clinical and neuropathologic Controls. AD cases had significantly increased amyloid beta (Aβ) peptide and paired helical filament– (PHF-) tau per area of neocortex that was proteinase K-sensitive, and significantly decreased amount of synaptophysin. We next investigated prefrontal cortex from 81 consecutive cases of high cognitive performers from the Adult Changes in Thought (ACT) study, a population-based study of brain aging and incident dementia. As expected, latent AD was common in this group; however, our results quantified widely individually-varying levels of Aβ peptides and PHF-tau among these high cognitive performers. This novel approach obtains quantitative data from population-based studies, and our initial studies with high cognitive performers provide important quantitative insights into latent AD that should help guide expectations from neuroimaging and prevention studies.
doi:10.1111/j.1750-3639.2011.00542.x
PMCID: PMC3295908  PMID: 21999410
4.  Adult Changes in Thought Study: Dementia is an Individually Varying Convergent Syndrome with Prevalent Clinically Silent Diseases that may be Modified by Some Commonly Used Therapeutics 
Current Alzheimer research  2012;9(6):718-723.
The Adult Changes in Thought (ACT) study is a longitudinal population-based prospective cohort study of brain aging and incident dementia in the Seattle metropolitan area. Observational studies using autopsies from ACT indicate that dementia is a convergent syndrome that commonly derives from Alzheimer’s disease (AD), microvascular brain injury (μVBI), and Lewy body disease (LBD), and that these diseases have prevalent subclinical forms that also are commonly co-morbid. The existence of subclinical diseases highlights potential opportunities to intervene before the development of clinically apparent impairments. Our observations suggest that some such interventions already may exist to suppress processes of AD (statin therapy) or μVBI (treatment of hypertension). Reduced burden of LBD is associated with cigarette smoking; although smoking is not recommended as an intervention, these exposure data may provide clues to alternative neuroprotective mechanisms. Self reported anti-oxidant supplementation was without apparent effect in this cohort on indices of AD, μVBI, or LBD. Continued observational studies of brain aging will provide further insight into the convergent complexity of the dementia syndrome and its subclinical forms as well as highlight potential interventions that will require validation in clinical trials.
PMCID: PMC3409333  PMID: 22471861
5.  Correlation of Alzheimer Disease Neuropathologic Changes With Cognitive Status: A Review of the Literature 
Clinicopathologic correlation studies are critically important for the field of Alzheimer disease (AD) research. Studies on human subjects with autopsy confirmation entail numerous potential biases that affect both their general applicability and the validity of the correlations. Many sources of data variability can weaken the apparent correlation between cognitive status and AD neuropathologic changes. Indeed, most persons in advanced old age have significant non-AD brain lesions that may alter cognition independently of AD. Worldwide research efforts have evaluated thousands of human subjects to assess the causes of cognitive impairment in the elderly, and these studies have been interpreted in different ways. We review the literature focusing on the correlation of AD neuropathologic changes (i.e. β-amyloid plaques and neurofibrillary tangles) with cognitive impairment. We discuss the various patterns of brain changes that have been observed in elderly individuals to provide a perspective for understanding AD clinicopathologic correlation and conclude that evidence from many independent research centers strongly supports the existence of a specific disease, as defined by the presence of Aβ plaques and neurofibrillary tangles. Although Aβ plaques may play a key role in AD pathogenesis, the severity of cognitive impairment correlates best with the burden of neocortical neurofibrillary tangles.
doi:10.1097/NEN.0b013e31825018f7
PMCID: PMC3560290  PMID: 22487856
Aging; Alzheimer disease; Amyloid; Dementia; Epidemiology; Neuropathology; MAPT; Neurofibrillary tangles
6.  Cognitive Activities During Adulthood Are More Important than Education in Building Reserve 
Cognitive reserve is thought to reflect life experiences. Which experiences contribute to reserve and their relative importance is not understood. Subjects were 652 autopsied cases from the Rush Memory and Aging Project and the Religious Orders Study. Reserve was defined as the residual variance of the regressions of cognitive factors on brain pathology and was captured in a latent variable that was regressed on potential determinants of reserve. Neuropathology variables included Alzheimer’s disease markers, Lewy bodies, infarcts, microinfarcts, and brain weight. Cognition was measured with six cognitive domain scores. Determinants of reserve were socioeconomic status (SES), education, leisure cognitive activities at age 40 (CA40) and at study enrollment (CAbaseline) in late life. The four exogenous predictors of reserve were weakly to moderately inter-correlated. In a multivariate model, all except SES had statistically significant effects on Reserve, the strongest of which were CA40 (β= .31) and CAbaseline (β= .28). The Education effect was negative in the full model (β= −.25). Results suggest that leisure cognitive activities throughout adulthood are more important than education in determining reserve. Discrepancies between cognitive activity and education may be informative in estimating late life reserve.
doi:10.1017/S1355617711000014
PMCID: PMC3498078  PMID: 23131600
Cognitive reserve; Alzheimer’s disease; Cerebrovascular disorders; Aging; Neuropsychological test battery; Multivariate analysis
7.  Role of Cerebrospinal Fluid and Plasma Biomarkers in the Diagnosis of Neurodegenerative Disorders and Mild Cognitive Impairment 
Biomarkers are one type of laboratory testing being developed in response to the therapeutic imperative for diseases that cause cognitive impairment and dementia. The role of biomarkers is already transforming the organization and conduct of clinical trials, and if successful will likely contribute in the future to the medical management of patients with these diseases. Despite the obvious utility of practicality of blood- or urine-based biomarkers, so far results from these fluid compartments have not been reproducible. In contrast, substantial progress has been made in cerebrospinal fluid biomarkers. Here we review the stages of cerebrospinal fluid biomarker development for several common and unusual diseases that cause cognitive impairment and dementia, stressing the distinction between diagnostic and mechanistic biomarkers. Future applications will likely focus on diagnosis of latent or early-stage disease, assessment of disease progression, mechanism of injury, and response to experimental therapeutics.
doi:10.1007/s11910-011-0212-0
PMCID: PMC3213691  PMID: 21725901
Alzheimer’s disease; Parkinson’s disease; vascular brain injury; biomarkers; cerebrospinal fluid; neurodegenerative disorders; mild cognitive impairment
8.  Alzheimer Disease Pathology in Subjects Without Dementia in Two Studies of Aging: The Nun Study and the Adult Changes in Thought Study 
Individuals with antemortem preservation of cognition who show autopsy evidence of at least moderate Alzheimer disease (AD) pathology suggest the possibility of brain reserve, that is, functional resistance to structural brain damage. This reserve would, however, only be relevant if the pathologic markers correlate well with dementia. Using data from the Nun Study (n = 498) and the Adult Changes in Thought (ACT) Study (n = 323), we show that Braak staging correlates strongly with dementia status. Moreover, participants with severe (Braak stage V–VI) AD pathology who remained not demented represent only 12% (Nun Study) and 8% (ACT study) of nondemented subjects. Comparison of these subjects to those who were demented revealed that the former group was often significantly memory impaired despite not being classified as demented. Most of these nondemented participants showed only stage V neurofibrillary pathology and frontal tangle counts that were slightly lower than a comparable (Braak stage V) dementia group. In summary, these data indicate that, in individuals with AD-type pathology who do not meet criteria for dementia, neocortical neurofibrillary tangles are somewhat reduced and incipient cognitive decline is present. Our data provide a foundation for helping to define additional factors that may impair, or be protective of, cognition in older adults.
doi:10.1097/NEN.0b013e31822e8ae9
PMCID: PMC3445265  PMID: 21937909
Adult Changes in Thought Study; Alzheimer disease; brain reserve; dementia; Nun Study; presymptomatic; preclinical
9.  Male Microchimerism in the Human Female Brain 
PLoS ONE  2012;7(9):e45592.
In humans, naturally acquired microchimerism has been observed in many tissues and organs. Fetal microchimerism, however, has not been investigated in the human brain. Microchimerism of fetal as well as maternal origin has recently been reported in the mouse brain. In this study, we quantified male DNA in the human female brain as a marker for microchimerism of fetal origin (i.e. acquisition of male DNA by a woman while bearing a male fetus). Targeting the Y-chromosome-specific DYS14 gene, we performed real-time quantitative PCR in autopsied brain from women without clinical or pathologic evidence of neurologic disease (n = 26), or women who had Alzheimer’s disease (n = 33). We report that 63% of the females (37 of 59) tested harbored male microchimerism in the brain. Male microchimerism was present in multiple brain regions. Results also suggested lower prevalence (p = 0.03) and concentration (p = 0.06) of male microchimerism in the brains of women with Alzheimer’s disease than the brains of women without neurologic disease. In conclusion, male microchimerism is frequent and widely distributed in the human female brain.
doi:10.1371/journal.pone.0045592
PMCID: PMC3458919  PMID: 23049819
10.  White Matter Lesions Defined by Diffusion Tensor Imaging in Older Adults 
Annals of neurology  2011;70(3):465-476.
Objective
The cellular and molecular mechanisms underlying MRI-defined white matter (WM) changes associated with age-related cognitive decline remain poorly defined. We tested the hypothesis that WM lesions in older adults, defined by diffusion tensor imaging (DTI), arise in the setting of vascular brain injury (VBI) and are characterized by increased free radical injury and aberrant oligodendrocyte lineage (OL) cell response to injury.
Methods
We undertook a multimodal analysis of prefrontal cortex (PFC) WM from twenty-five autopsies derived from a population-based cohort where VBI and Alzheimer's Disease (AD) frequently coincide. Ex-vivo high field strength DTI measurements of fractional anisotropy (FA), apparent diffusion coefficient (ADC), and axial (D∥) and radial (D⊥) diffusivity were measured at high magnetic field strength (11.7 T) and analyzed relative to quantitative in vivo biomarkers of free radical injury, an OL-specific marker Olig2, and histologic evaluation of hyaluronan (HA), an inhibitor of OL maturation.
Results
Coincident AD and VBI showed significant association with lower FA and a robust relationship between decreasing FA and increasing D⊥. Free radical injury to docosahexaenoate and adrenate in PFC WM was significantly elevated in cases with VBI independent of AD, and were inversely correlated with FA. Similarly, increased density of Olig2-immunoreactive cells in PFC WM was significantly associated with VBI independent of AD and co-localized with regions enriched in HA.
Interpretation
DTI-defined PFC WM lesions in older individuals are characterized by free radical injury to myelin and neuro-axonal elements that coincides with pronounced expansion of the pool of OL cells in HA-rich regions.
doi:10.1002/ana.22484
PMCID: PMC3177155  PMID: 21905080
white matter; vascular brain injury; Alzheimer's disease; diffusion tensor imaging; oxidative damage; oligodendroglia
11.  Ecology of aging human brain 
Archives of neurology  2011;68(8):1049-1056.
OBJECTIVE
Alzheimer’s disease (AD), cerebral vascular brain injury (VBI), and isocortical Lewy body (LB) disease (LBD) are the major contributors to dementia in community- or population-based studies: Adult Changes in Thought (ACT) study, Honolulu-Asia Aging Study (HAAS), Nun Study (NS), and Oregon Brain Aging Study (OBAS). However, the prevalence of clinically silent forms of these diseases in cognitively normal (CN) adults is less clear.
DESIGN and SETTING
We evaluated 1672 brain autopsies from ACT, HAAS, NS, and OBAS of which 424 met criteria for CN.
MAIN OUTCOME MEASURES
Of these, 336 cases had a comprehensive neuropathologic examination of neuritic plaque (NP) density, Braak stage for neurofibrillary tangles (NFTs), Lewy body (LB) distribution, and number of cerebral microinfarcts (CMIs).
RESULTS
47% of CN cases had moderate or frequent NP density; of these 6% also had Braak stage V or VI for NFTs. 15% of CN cases had medullary LBD; 8% also had nigral and 4% isocortical LBD. The presence of any CMIs was identified in 33% and high level CMIs in 10% of CN individuals. Overall burden of lesions in each individual and their co-morbidity varied widely within each study but were similar among studies.
CONCLUSIONS
These data show an individually varying complex convergence of subclinical diseases in the brain of older CN adults. Appreciating this ecology should help guide future biomarker or neuroimaging studies as well as clinical trials that focus on community- or population-based cohorts.
doi:10.1001/archneurol.2011.157
PMCID: PMC3218566  PMID: 21825242
Alzheimer’s disease; vascular brain injury; Lewy body disease; cognitive aging
12.  Neuropathological Associates of Multiple Cognitive Functions in Two Community-Based Cohorts of Older Adults 
Studies of neuropathology-cognition associations are not common and have been limited by small sample sizes, long intervals between autopsy and cognitive testing, and lack of breadth of neuropathology and cognition variables. This study examined domain-specific effects of common neuropathologies on cognition using data (N = 652) from two large cohort studies of older adults. We first identified dimensions of a battery of 17 neuropsychological tests, and regional measures of Alzheimer’s disease (AD) neuropathology. We then evaluated how cognitive factors were related to dimensions of AD and additional measures of cerebrovascular and Lewy Body disease, and also examined independent effects of brain weight. All cognitive domains had multiple neuropathology determinants that differed by domain. Neocortical neurofibrillary tangles were the strongest predictors of most domains, while medial temporal tangles showed a weaker relationship with episodic memory. Neuritic plaques had relatively strong effects on multiple domains. Lewy bodies and macroscopic infarcts were associated with all domains, while microscopic infarcts had more limited associations. Brain weight was related to all domains independent of specific neuropathologies. Results show that cognition is complexly determined by multiple disease substrates. Neuropathological variables and brain weight contributed approximately a third to half of the explained variance in different cognitive domains.
doi:10.1017/S1355617710001426
PMCID: PMC3376403  PMID: 21092373
Latent variable analysis; Confirmatory factor analysis; Neuropathology; MIMIC; Cerebrovascular disease; Neuropsychological test battery
13.  Hippocampal sclerosis in advanced age: clinical and pathological features 
Brain  2011;134(5):1506-1518.
Hippocampal sclerosis is a relatively common neuropathological finding (∼10% of individuals over the age of 85 years) characterized by cell loss and gliosis in the hippocampus that is not explained by Alzheimer’s disease. Hippocampal sclerosis pathology can be associated with different underlying causes, and we refer to hippocampal sclerosis in the aged brain as hippocampal sclerosis associated with ageing. Much remains unknown about hippocampal sclerosis associated with ageing. We combined three different large autopsy cohorts: University of Kentucky Alzheimer’s Disease Centre, the Nun Study and the Georgia Centenarian Study to obtain a pool of 1110 patients, all of whom were evaluated neuropathologically at the University of Kentucky. We focused on the subset of cases with neuropathology-confirmed hippocampal sclerosis (n = 106). For individuals aged ≥95 years at death (n = 179 in our sample), each year of life beyond the age of 95 years correlated with increased prevalence of hippocampal sclerosis pathology and decreased prevalence of ‘definite’ Alzheimer’s disease pathology. Aberrant TAR DNA protein 43 immunohistochemistry was seen in 89.9% of hippocampal sclerosis positive patients compared with 9.7% of hippocampal sclerosis negative patients. TAR DNA protein 43 immunohistochemistry can be used to demonstrate that the disease is usually bilateral even when hippocampal sclerosis pathology is not obvious by haematoxylin and eosin stains. TAR DNA protein 43 immunohistochemistry was negative on brain sections from younger individuals (n = 10) after hippocampectomy due to seizures, who had pathologically confirmed hippocampal sclerosis. There was no association between cases with hippocampal sclerosis associated with ageing and apolipoprotein E genotype. Age of death and clinical features of hippocampal sclerosis associated with ageing (with or without aberrant TAR DNA protein 43) were distinct from previously published cases of frontotemporal lobar degeneration TAR DNA protein 43. To help sharpen our ability to discriminate patients with hippocampal sclerosis associated with ageing clinically, the longitudinal cognitive profile of 43 patients with hippocampal sclerosis associated with ageing was compared with the profiles of 75 controls matched for age, gender, education level and apolipoprotein E genotype. These individuals were followed from intake assessment, with 8.2 (average) longitudinal cognitive assessments. A neuropsychological profile with relatively high-verbal fluency but low word list recall distinguished the hippocampal sclerosis associated with ageing group at intake (P < 0.015) and also 5.5–6.5 years before death (P < 0.005). This may provide a first step in clinical differentiation of hippocampal sclerosis associated with ageing versus pure Alzheimer’s disease in their earliest stages. In summary, in the largest series of autopsy-verified patients with hippocampal sclerosis to date, we characterized the clinical and pathological features associated with hippocampal sclerosis associated with ageing.
doi:10.1093/brain/awr053
PMCID: PMC3097889  PMID: 21596774
biomarkers; PGRN; epilepsy; FTLD; cerebrovascular; stroke
14.  A novel mutation in FHL1 in a family with X-linked scapuloperoneal myopathy: phenotypic spectrum and structural study of FHL1 mutations 
An X-linked myopathy was recently associated with mutations in the four-and-a-half-LIM domains 1 (FHL1) gene. We identified a family with late onset, slowly progressive weakness of scapuloperoneal muscles in three brothers and their mother. A novel missense mutation in the LIM2 domain of FHL1 (W122C) co-segregated with disease in the family. The phenotype was less severe than that in other reported families. Muscle biopsy revealed myopathic changes with FHL1 inclusions that were ubiquitin- and desmin-positive. This mutation provides additional evidence for X-linked myopathy caused by a narrow spectrum of mutations in FHL1, mostly in the LIM2 domain. Molecular dynamics (MD) simulations of the newly identified mutation and five previously published missense mutations in the LIM2 domain revealed no major distortions of the protein structure or disruption of zinc binding. There were, however, increases in the nonpolar, solvent-accessible surface area in one or both of two clusters of residues, suggesting that the mutant proteins have a variably increased propensity to aggregate. Review of the literature shows a wide range of phenotypes associated with mutations in FHL1. However, recognizing the typical scapuloperoneal phenotype and X-linked inheritance pattern will help clinicians arrive at the correct diagnosis.
doi:10.1016/j.jns.2010.06.017
PMCID: PMC3016010  PMID: 20633900
X-linked myopathy; scapuloperoneal; FHL1; neurogenetics; muscular dystrophy; genetic diagnosis
15.  Pathologic correlates of dementia in individuals with Lewy body disease 
Cognitive impairment and dementia are more common in patients with Parkinson disease (PD) than age-matched controls, and appear to become more frequent as PD progresses. However, estimates of dementia in patients with PD have varied widely, likely due in part to differences in case definition, case ascertainment, and methodology. First, we review investigations of usual pathologic correlates of dementia in patients with brainstem (b) Lewy Body Disease (LBD) and report our findings from the initial 266 brain autopsies from a population-based study of brain aging and incident dementia. Our results showed that 2.6% of subjects were diagnosed with PD during life but that 20% had bLBD at autopsy. Seventy percent of individuals with bLBD had high-level of one or more cerebral pathologic changes significantly associated with dementia: Alzheimer's disease (AD), cerebral (c) LBD, or microvascular brain injury (μVBI); these were commonly co-morbid. Next we consider proposed contributors to cognitive impairment and dementia in the approximately 30% of patients with only bLBD, including regionally selective dendritic degeneration of neostriatal medium spiny neurons. Diseases contributing to cognitive impairment and dementia in patients with bLBD are heterogeneous, providing diagnostic challenges as well as multiple opportunities for successful intervention in patients with PD.
doi:10.1111/j.1750-3639.2009.00371.x
PMCID: PMC2881486  PMID: 20522091
16.  Cerebrospinal Fluid Biomarkers in Mild Cognitive Impairment and Dementia 
Given the magnitude of the public health problem of dementia in the elderly, there is a pressing need for research, development, and timely application of biomarkers that will identify latent and prodromal illness as well as dementia. Although identification of risk factors and neuroimaging measures will remain key to these efforts, this review focuses on recent progress in the discovery, validation, and standardization of cerebrospinal fluid (CSF) biomarkers, small molecules and macromolecules whose CSF concentration can aid in diagnosis at different stages of disease as well as in assessment of disease progression and response to therapeutics. A multimodal approach that brings independent information from risk factor assessment, neuroimaging, and biomarkers may soon guide physicians in the early diagnosis and management of cognitive impairment in the elderly.
doi:10.3233/JAD-2010-1236
PMCID: PMC2891184  PMID: 20061646
Alzheimer’s disease; biomarkers; cerebrospinal fluid; Lewy body disease; vascular cognitive impairment
17.  Association between lifetime cigarette smoking and Lewy body accumulation 
Cigarette smoking has been associated repeatedly in observational studies with decreased risk of Parkinson's disease (PD), but its relationship to the risk of dementia or Alzheimer's disease (AD) is inconsistent. All of these studies have used clinical diagnoses of disease. We tested the hypothesis that lifetime cigarette use might be associated with reduced risk of neuropathologic changes of Lewy-related pathology (LRP) in multiple brain regions or with reduced risk of consensus neuropathologic changes of AD in a prospective community-based study of brain aging and dementia, the Adult Changes in Thought (ACT) study. We observed that heavy lifetime cigarette smoking (> 50 pack years) was associated with significantly reduced relative risk (RR) for LRP, but not AD-type pathologic changes, after correcting for selection bias, and with significantly reduced frequency of LRP in the substantia nigra. These findings are the first of which we are aware to associate reduced LRP in human brain with any exposure, and substantiate observational studies that have associated cigarette smoking with reduced risk of PD. Although cigarette smoking is too toxic to suggest as a treatment, if confirmed, these findings may guide future therapeutic strategies that attempt to suppress LRP in human brain by other means.
doi:10.1111/j.1750-3639.2009.00296.x
PMCID: PMC2864364  PMID: 19531100
Alzheimer's disease; Lewy body; smoking; neuropathology
18.  Blood Pressure and Brain Injury in Older Adults: Findings from a Community-Based Autopsy Study 
OBJECTIVES
We examined correlations between blood pressure and dementia-related pathologic brain changes in a community-based autopsy sample.
DESIGN
Prospective cohort study.
SETTING
A large health maintenance organization in Seattle, Washington.
PARTICIPANTS
A cohort of 250 participants who were ≥ 65 years old and cognitively normal at time of enrollment in the Adult Changes in Thought (ACT) study, and who underwent autopsy.
MEASUREMENTS
Blood pressure and history of antihypertensive treatment were taken at enrollment. A linear regression model was used to examine the relationship between blood pressure (systolic and diastolic blood pressure) at enrollment and pathologic changes in cerebrum (cystic macroscopic infarcts, microinfarcts, neuritic plaques, neurofibrillary tangles, and cortical Lewy bodies).
RESULTS
The presence of more than 2 microinfarcts, but not any other pathologic change, was independently associated with systolic (SBP) in younger participants (age 65–80, n=137), but not in older participants (age >80, n=91). The relative risk (RR) for >2 microinfarcts with each 10 mmHg increase in SBP was 1.15 (95% confidence interval (CI): 1.00, 1.33) in the younger participants, adjusted for age-at-entry, gender, and time to death. This RR was particularly strong in younger participants not taking antihypertensive medications (RR: 1.48; 95% CI: 1.21, 1.81); significant associations were not observed in participants treated for hypertension. Findings for diastolic blood pressure were negative.
CONCLUSION
The association between elevated SBP and cerebrovascular damage in untreated older adults (age 65–80) suggests that adequate hypertension treatment may reduce dementia risk by minimizing microvascular injury to cerebrum.
doi:10.1111/j.1532-5415.2009.02493.x
PMCID: PMC2818442  PMID: 19793158
dementia; blood pressure; hypertension; neuropathology; autopsy
19.  Quantitation and Mapping of Cerebral Detergent-Insoluble Proteins in the Elderly 
Accumulation of abnormal protein aggregates, detergent-insoluble (DI) proteins and amyloid in the brain are shared features of many neurodegenerative diseases. Previous studies correlating DI proteins and cognitive performance are limited. We addressed these limitations using two sets of autopsy brains, one selected from our Alzheimer’s Disease Research Center and the other an unselected series from Adult Changes in Thought (ACT), a population-based study of brain aging. We observed concentrations of 11 proteins and 6 protein variants that can be grouped into three highly correlated clusters: amyloid (A)β, tau and alpha-synuclein (α-syn). While abnormal proteins from each cluster independently correlated with cognitive performance in ACT participants, only increased soluble Aβ oligomers in temporal cortex and increased DI Aβ 42 and DI α-syn in prefrontal cortex were negatively correlated with cognitive performance. These data underscore the therapeutic imperative to suppress processes leading to accumulation of soluble Aβ oligomers, DI Aβ 42 and DI α-syn, highlight an at least partially independent contribution to cognitive impairment and raise the possibility that the priority for therapeutic targets may vary by brain region in a typical elderly US population.
doi:10.1111/j.1750-3639.2008.00190.x
PMCID: PMC2704248  PMID: 18652590
20.  Neuropathology-Based Risk Scoring for Dementia Diagnosis in the Elderly 
Current neuropathologic consensus criteria for diagnosis of dementia yield a classification of processes that likely contributed to dementia in that individual. While dementia diagnosis currently relies on clinical criteria, practicing neuropathologists and researchers might benefit from a simple, accurate risk scoring protocol for the neuropathologic diagnosis of dementia. Using 232 consecutive autopsies from the population-based Adult Changes in Thought study, we developed two logistic regression-based risk scoring systems; one solely using neuropathologic measures and a second additionally including demographic information. Inverse-probability weighting was used to adjust for inherent selection bias in autopsy-based studies of dementing illnesses. Both systems displayed high levels of predictive accuracy; bias-adjusted area-under-the-curve statistics were 0.78 (95% CI 0.71, 0.85) and 0.87 (95% CI 0.83, 0.92), indicating improved performance with the inclusion of demographic characteristics, specifically age and birth cohort information. Application of the combined neuropathlogy/demographic model yielded bias-adjusted sensitivity and specificity of 81% each. In contrast, application of NIA-Reagan criteria yielded sensitivity and specificity of 53% and 84%. Our proposed scoring systems provide neuropathologists with tools to make a diagnosis, and interpret their diagnosis in the light of known sensitivity and specificity estimates. Evaluation in independent samples will be important to verify our findings.
doi:10.3233/JAD-2009-1105
PMCID: PMC2852462  PMID: 19542615
Alzheimer's disease; autopsy; dementia; microinfarcts; neuropathology; prediction; selection bias
21.  Elevated Ratio of Urinary Metabolites of Thromboxane and Prostacyclin Is Associated with Adverse Cardiovascular Events in ADAPT 
PLoS ONE  2010;5(2):e9340.
Results from prevention trials, including the Alzheimer's Disease Anti-inflammatory Prevention Trial (ADAPT), have fueled discussion about the cardiovascular (CV) risks associated with non-steroidal anti-inflammatory drugs (NSAIDs). We tested the hypotheses that (i) adverse CV events reported among ADAPT participants (aged 70 years and older) are associated with increased ratio of urine 11-dehydrothromboxane B2 (Tx-M) to 2′3-donor–6-keto-PGF1 (PGI-M) attributable to NSAID treatments; (ii) coincident use of aspirin (ASA) would attenuate NSAID-induced changes in Tx-M/PGI-M ratio; and (iii) use of NSAIDs and/or ASA would not alter urine or plasma concentrations of F2-isoprostanes (IsoPs), in vivo biomarkers of free radical damage. We quantified urine Tx-M and PGI-M, and urine and plasma F2-IsoPs from 315 ADAPT participants using stable isotope dilution assays with gas chromatography/mass spectrometry, and analyzed these data by randomized drug assignment and self-report compliance as well as ASA use. Adverse CV events were significantly associated with higher urine Tx-M/PGI-M ratio, which seemed to derive mainly from lowered PGI-M. Participants taking ASA alone had reduced urine Tx-M/PGI-M compared to no ASA or NSAID; however, participants taking NSAIDs plus ASA did not have reduced urine Tx-M/PGI-M ratio compared to NSAIDs alone. Neither NSAID nor ASA use altered plasma or urine F2-IsoPs. These data suggest a possible mechanism for the increased risk of CV events reported in ADAPT participants assigned to NSAIDs, and suggest that the changes in the Tx-M/PGI-M ratio was not substantively mitigated by coincident use of ASA in individuals 70 years or older.
doi:10.1371/journal.pone.0009340
PMCID: PMC2824826  PMID: 20174466
22.  Free radical damage to cerebral cortex in Alzheimer's Disease, Microvascular Brain Injury, and Smoking 
Annals of neurology  2009;65(2):226-229.
Evidence supports a pathogenic role for free radical injury to brain regions in Alzheimer's disease (AD); however, clinical trial results are only mildly encouraging. Examining brains from The Adult Changes in Thought study offers a unique perspective. Selectively increased free radical damage to cerebral cortex was associated with AD, microvascular brain injury (μ-VBI), and current smoking, but not with antioxidant supplement usage. Our results support suppression of free radical injury to brain as a therapeutic target for AD and μ-VBI; however, future clinical trials should consider other antioxidants or doses than those identified in our study.
doi:10.1002/ana.21508
PMCID: PMC2729331  PMID: 19259965
23.  Different Patterns of Cerebral Injury in Dementia with or Without Diabetes 
Archives of neurology  2009;66(3):315-322.
Background
Diabetes mellitus (DM) increases the risk of dementia in the elderly. However the underlying mechanisms, its connection with Alzheimer's disease (AD) and vascular cognitive impairment (VCI), and effects of therapy remain unclear.
Objective
To test the hypothesis that DM promotes specific neuropathologic processes that contribute to dementia and that these processes may be suppressed by antidiabetic therapy.
Design
A comprehensive neuropathologic assessment of all cases from a community-based study of incident dementia (Adult Changes in Thought study) that underwent autopsies (n=259) and had information on DM status (n=196). Biochemical analysis was conducted on a subset of these cases with rapidly frozen brain tissue (n=57).
Participants
Autopsy cases were divided into four groups: no DM/no dementia (DM−/dementia−), DM/no dementia (DM+/dementia−), no DM/dementia (DM−/dementia+), and DM/dementia (DM+/ dementia+). Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) diagnosis of dementia was assigned through a consensus of experts following biennial cognitive and physical evaluations. Diabetes was diagnosed based on information obtained from participants’ extensive medical records.
Results
In cases without dementia (n=125), neuropathologic or biochemical endpoints did not differ significantly by DM status. However, we observed 2 patterns of injury in patients with dementia (n=71) by their DM status. Individuals without DM, but with dementia (DM−/dementia+) had greater Aβ peptide load and increased F2-isoprostanes in the cerebral cortex, while DM+/dementia+ patients had more microvascular infarcts (MVI) and an increased cortical IL-6 (interleukin 6) concentration. The number of microvascular infarcts was greater in deep cerebral structures in patients with dementia whose diabetes was treated, whereas amyloid plaque load tended to be greater for untreated diabetic patients with dementia.
Conclusions
These novel characterizations of 2 different patterns of cerebral injury in patients with dementia depending on DM status may have etiologic and therapeutic implications.
doi:10.1001/archneurol.2008.579
PMCID: PMC2766529  PMID: 19139294
24.  Biomarkers for cognitive impairment and dementia in elderly people 
Lancet neurology  2008;7(8):704-714.
The threat of a looming pandemic of dementia in elderly people highlights the compelling need for the development and validation of biomarkers that can be used to identify pre-clinical and prodromal stages of disease in addition to fully symptomatic dementia. Although predictive risk factors and correlative neuroimaging measures will have important roles in these efforts, this Review describes recent progress in the discovery, validation, and standardization of molecular biomarkers – small molecules and macromolecules whose concentration in brain or biological fluids can aid in diagnosis at different stages of the more common dementing diseases and in the assessment of disease progression and response to therapeutics. An approach that efficiently combines independent information from risk factor assessment, neuroimaging measures, and biomarkers may soon guide clinicians in the early diagnosis and management of cognitive impairment in elderly people.
doi:10.1016/S1474-4422(08)70162-5
PMCID: PMC2710375  PMID: 18635019

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