of Alzheimers Disease
Dr. Jos L Molinuevo
Alzheimers disease and other cognitive disorders unit
ICN, Hospital Clinic I Universitari, Barcelona
BarcelonaBeta Brain Research Centre
Fundaci Pasqual Maragall
Probable AD diagnosis
Possible AD diagnosis
original publication
Current clinical AD diagnostic methods Dr Alzheimers
(Bielchowsky's technique)
shows much variability among studies
General impression that clinical diagnosis is
accurate
xx
No AD
pathology
Yes AD
pathology
No probable
AD (clinical)
213
180
NPV=54
%
Probable AD
(clinical)
88
438
PPV=83
%
Specificity
=
70.8%
Sensitivity
=
70.9%
Pathological diagnosis:
moderate or frequent plaques AND Braak* IVVI
*Braak IV-VI it is the needed pathological threshold to make the pathological diagnosis of AD
AD, Alzheimers disease, NINCDS-ADRDA, Mational Institute of Neurological and Communicative Disorders and Stroke-Alzheimers Disease and Related Disorders Association;
1. Beach TG, et al. J Neuropathol Exp Neurol 2012;71(4):26673; Consensus recommendations for the postmortem diagnosis of Alzheimer's disease. The National Institute on Aging, and
Reagan Institute Working Group on Diagnostic Criteria for the Neuropathological Assessment of Alzheimer's Disease. Neurobiol Aging 1997;18:S1S2
Normal
AD Preclinical Stage
Normal
pathology
No symptoms
Incipient AD
pathology
No symptoms
Medical attention
Differential diagnosis
Mild Cognitive
Impairment due to AD
Moderate pathology
Dementia due to AD
Intense
pathology
Memory disorders
Pathological continuum
Dementia
Preclinical AD
The preclinical stage has been postulated to be a
long asymptomatic period during which the
pathophysiological process is progressing.
Preclinical AD subjects have been defined as
individuals who have evidence of early AD
pathological changes but do not meet clinical
criteria for MCI or dementia (Sperling et al., 2011).
Presymptomatic subjects: this state applies to
individuals who will develop AD (monogenic AD)
Asymptomatic at risk state for AD: this state can
be identified in vivo by evidence of amyloidosis of
the brain (PET or CSF).
Presymptomatic subjects
41 participants (May 2014):
11 symptomatic mutations carriers (SMC)
16 asymptomatic mutation carriers (AMC)
(mean age -16y Estimated age of onset)
14 asymptomatic non-carriers (NC)
Clinical and cognitive evaluations
Blood and CSF biomarkers
Structural and functional MRI
Amyloid-PET
FDG-PET
Presymptomatic subjects
AMC
A42 or A42/ptau vs EAO
Spearman rho 0,771
p= 0,036
N=6
Interpretation: At early preclinical stages, CTh in PPC and posterior association areas and
caudate volume increase in PSEN1 MC and decrease thereafter with disease progression.
These findings are concurrent with reduced MD suggesting underlying microstructural
changes in the GM.
Reactive neuronal hypertrophy or/and inflammation may account for these features in AMC.
13 AMC vs 14 NC
AMC: mean age -16,6y EAO
Longitudinal study
Cross-sectional study
~12/13 years
Presymptomatic AD
Asymptomatic at risk
Digit-symbol substitution
WMS delayed
16
14
Recall score
12
10
8
6
4
2
0
60
50
40
30
20
10
0
A-
A+
A-
A+
A-
A+
A 1-42
(<495 pg/ml)
11
66.0 (6.4)
73.6 (6.3)
A 1-42
680.2 (139.6)
315.8 (81.3)**
t-tau
401.1 (294.3)
585.3 (750.1)
p-tau
67.3 (40.2)
82.7 (74.2)
28.2 (1.3)
26.5 (1.8)
51.3 (4.6)
50.0 (2.8)
FCSRT-total recall
14.4 (1.3)
10.8 (1.6)**
n
Age (years)
**p<0.005
FCSRI=Free and Cued Selective Reminding Test
(r=0.666; p<0.005)
(r=0.697; p<0.005)
CTh
CTh
CTh
CTh
CTh
Fig. 2. Scatter plots showing interactions between cognitive reserve proxies and A -related areas of cortical thinning or atrophy in elderly with
normal versus abnormal A 42 CSF levels. In red, statistically signicant correlation coefcients (see Results for statistical details). Cth, cortical
thickness, CR, cognitive reserve.
Relationship between the areas showing increased AxD and the level of
A42 on CSF (r=-0.52, p<0.0001) and cognitive reserve (Pre-AD group
r=0.57, p<0.012).
YKL40: GLIAL
INFLAMMATORY RESPONSE
YKL40: GLIAL
INFLAMMATORY RESPONSE
Correlations between CSF YKL-40 levels with A42), t-tau and p-tau,
performed by partial correlation models with age as co-variate. (A) all
sample excluding iRBD group, (B) Preclinical AD (Pre-AD) subjects.
Statistical significance was observed for tau biomarkers in both
Preclinical AD
CSF and imaging biomarkers present interactive
dynamics along the AD continuum
The preclinical stage is biologically active, showing
AD signature areas an initial increase in cortical
thickness and posterior decrease before the clinical
appearance of cognitive impairment
Preclinical AD present distinct functional activity in
key encoding regions
This stage may last around 15-20 years
Normal
AD Preclinical Stage
Normal
pathology
No symptoms
Incipient AD
pathology
No symptoms
Medical attention
Differential diagnosis
Mild Cognitive
Impairment due to AD
Moderate pathology
Dementia due to AD
Intense
pathology
Memory disorders
Pathological continuum
Dementia
FEW correction:
parahippocampal
gyrus,
uncus, precuneus
and
medial frontal
gyrus (left)
Clinical evolution
All patients followed over 2 years converted to AD according
to NINCDS-ADRDA criteria (2 or more cognitive areas
affected plus significant daily living activities impairment
according to FAQ).
All patients followed one year had lower cognition (3 of them
with 2 or more cognitive areas affected) and one with lower
functionality (only memory affected)
Patients followed less than one year no significantly
cognitive (number of cognitive areas affected) or functional
changes.
Prodromal or predementia AD
Alzheimers disease may be diagnosed
through a clinic-biological approach
The prodromal, predementia or MCI stage
represents the earliest phase to establish a
clinical diagnosis
Biologic: biomarkers correlate with pathology
Clinic: episodic memory is a specific symptom
41
Injury markers
Imaging:
FDG PET
SPECT
MRI: hippocampal volume or atrophy rate
Biomarker probability of AD
Amyloid Markers
Injury markers
aetiology
Uninformative
Intermediate
Highest
Untested, conflicting,
indeterminant or non
informative results
Untested, conflicting,
indeterminant or non
informative results
Positive
Unavailable
Unavailable
Positive
Positive
Positive
Negative
Negative
Thank You