Alzheimers progression tracked prior to dementia

(via Yottafire & The Lancet Neruology, Dec 15th 2013)

Analysis Scientists from the Washington University in St. Louis have recently validated a three-stage classification system for Alzheimers disease. The researchers examined subjects and identified them as either belonging to one of three Alzheimers stages, being free of cognitive impairment, having a suspected non-Alzheimers pathophysiology or remaining unclassified. Only 5 out of 311 participants were unclassifiable. The researchers believe that their system could facilitate improvements to treatment by focusing interventions on patients who are still in the preclinical first stage.

Stephanie JB Vos MSc, Prof Chengjie Xiong PhD, Pieter Jelle Visser MD, Mateusz S Jasielec MS, Jason Hassenstab PhD , Elizabeth A Grant PhD, Prof Nigel J Cairns PhD, Prof John C Morris MD, Prof David M Holtzman MD, ProfAnne M Fagan PhD

Summary
Background New research criteria for preclinical Alzheimer's disease have been proposed, which include stages for cognitively normal individuals with abnormal amyloid markers (stage 1), abnormal amyloid and neuronal injury markers (stage 2), or abnormal amyloid and neuronal injury markers and subtle cognitive changes (stage 3). We aimed to investigate the prevalence and long-term outcome of preclinical Alzheimer's disease according to these criteria.

Methods Participants were cognitively normal (clinical dementia rating [CDR]=0) community-dwelling volunteers aged at least 65 years who were enrolled between 1998 and 2011 at the Washington University School of Medicine (MO, USA). CSF amyloid-142 and tau concentrations and a memory composite score were used to classify participants as normal (both markers normal), preclinical Alzheimer's disease stage 13, or suspected non-Alzheimer pathophysiology (SNAP, abnormal injury marker without abnormal amyloid marker). The primary outcome was the proportion of participants in each preclinical AD stage. Secondary outcomes included progression to CDR at least 05, symptomatic Alzheimer's disease (score of at least 05 for memory and at least one other domain and cognitive impairments deemed to be due to Alzheimer's disease), and mortality. We undertook survival analyses using subdistribution and standard Cox hazards models and linear mixed models. Findings Of 311 participants, 129 (41%) were classed as normal, 47 (15%) as stage 1, 36 (12%) as stage 2, 13 (4%) as stage 3, 72 (23%) as SNAP, and 14 (5%) remained unclassified. The 5-year progression rate to CDR at least 05, symptomatic Alzheimer's disease was 2% for participants classed as normal, 11% for stage 1, 26% for stage 2, 56% for stage 3, and 5% for SNAP. Compared with individuals classed as normal, participants with preclinical Alzheimer's disease had an increased risk of death after adjusting for covariates (hazard ratio 62, 95% CI 11 350; p=0040). Interpretation Preclinical Alzheimer's disease is common in cognitively normal elderly people and is associated with future cognitive decline and mortality. Thus, preclinical Alzheimer's disease could be an important target for therapeutic intervention. Funding National Institute of Aging of the National Institutes of Health (P01-AG003991, P50-AG05681, P01-AG02676), Internationale Stichting Alzheimer Onderzoek, the Center for Translational Molecular Medicine project LeARN, the EU/EFPIA Innovative Medicines Initiative Joint Undertaking, and the Charles and Joanne Knight Alzheimer Research Initiative.

Synoposis For years, scientists have attempted to understand how Alzheimers disease harms the brain before memory loss and dementia are clinically detectable. Most researchers think this preclinical stage, which can last a decade or more before symptoms appear, is the critical phase when the disease might be controlled or stopped, possibly preventing the failure of memory and thinking abilities in the first place. Important progress in this effort is reported in October in Lancet Neurology. Scientists at the Charles F. and Joanne Knight Alzheimer Disease Research Center at Washington University School of Medicine in St. Louis, working in collaboration with investigators at the University of Maastricht in the Netherlands, helped to validate a proposed new system for identifying and classifying individuals with preclinical Alzheimers disease. Their findings indicate that preclinical Alzheimers disease can be detected during a persons life, is common in cognitively normal elderly people and is associated with future mental decline and mortality. According to the scientists, this suggests that preclinical Alzheimers disease could be an important target for therapeutic intervention. A panel of Alzheimers experts, convened by the National Institute on Aging in association with the Alzheimers Association, proposed the classification system two years ago. It is based on earlier efforts to define and track biomarker changes during preclinical disease. According to the Washington University researchers, the new findings offer reason for encouragement, showing, for example, that the system can help predict which cognitively normal individuals will develop symptoms of Alzheimers and how rapidly their brain function will decline. But they also highlight additional questions that must be answered before the classification system can be adapted for use in clinical care. For new treatments, knowing where individuals are on the path to Alzheimers dementia will help us improve the design and assessment of clinical trials, said senior author Anne Fagan, PhD, research professor of neurology. There are many steps left before we can apply this system in the clinic, including standardizing how we gather and assess data in individuals, and determining which of our indicators of preclinical disease are the most accurate. But the research data are compelling and very encouraging.

The classification system divides preclinical Alzheimers into three stages: Stage 1: Levels of amyloid beta, a protein fragment produced by the brain, begin to fall in the spinal fluid. This indicates that the substance is beginning to form plaques in the brain. Stage 2: Levels of tau protein start to rise in the spinal fluid, indicating that brain cells are beginning to die. Amyloid beta levels are still abnormal and may continue to fall. Stage 3: In the presence of abnormal amyloid and tau biomarker levels, subtle cognitive changes can be detected by neuropsychological testing. By themselves, these changes cannot establish a clinical diagnosis of dementia. The researchers applied these criteria to research participants studied from 1998 through 2011 at the Knight Alzheimer Disease Research Center. The center annually collects extensive cognitive, biomarker and other health data on normal and cognitively impaired volunteers for use in Alzheimers studies. The scientists analyzed information on 311 individuals age 65 or older who were cognitively normal when first evaluated. Each participant was evaluated annually at the center at least twice; the participant in this study with the most data had been followed for 15 years. At the initial testing, 41 percent of the participants had no indicators of Alzheimers disease (stage 0); 15 percent were in stage 1 of preclinical disease; 12 percent were in stage 2; and 4 percent were in stage 3. The remaining participants were classified as having cognitive impairments caused by conditions other than Alzheimers (23 percent) or did not meet any of the proposed criteria (5 percent). A total of 31 percent of our participants had preclinical disease, said Fagan. This percentage matches findings from autopsy studies of the brains of older individuals, which have shown that about 30 percent of people who were cognitively normal had preclinical Alzheimers pathology in their brain.

Scientists believe the rate of cognitive decline increases as people move through the stages of preclinical Alzheimers. The new data support this idea. Five years after their initial evaluation, 11 percent of the stage 1 group, 26 percent of the stage 2 group, and 52 percent of the stage 3 group had been diagnosed with symptomatic Alzheimers. Individuals with preclinical Alzheimers disease were six times more likely to die over the next decade than older adults without preclinical Alzheimers disease, but researchers dont know why. Risk factors for Alzheimers disease might also be associated with other life-threatening illnesses, Fagan said. Its also possible that the presence of Alzheimers hampers the diagnosis and treatment of other conditions or contributes to health problems elsewhere in the body. We dont have enough data yet to say, but its an issue were continuing to investigate.