Alzheimer's Disease

First Description of AD

In 1907, Alois Alzheimer, a German physician from Bavaria, published the case of one of his patients. The patient, Mrs. Auguste D., at the age of fifty-one years developed an unfounded jealousy regarding her husband. This behavioral change was followed closely by a subtle and slow decline in other cognitive abilities, including memory, orientation to time and to physical location, language, and the ability to perform learned behaviors. All of her difficulties gradually progressed in severity. Within three years, the patient did not recognize her family or herself, could not maintain her self-care, and was institutionalized. She died a short four and a half years after her illness began. Her brain was removed at autopsy. Using a novel (at the time) silver stain to highlight changes in brain sections, Dr. Alzheimer viewed the tissue under his microscope. He described what are now the pathologic lesions of the disease that bears his name: loss of neurons, senile plaques found in the brain substance but outside of the neurons, and neurofibrillary tangles found inside neurons.

Dr. Alzheimer's patient had developed dementia. Dementia is an acquired and continuing loss of thinking abilities in three or more areas of cognition (which include memory, language, orientation, calculation, judgment, personality, and other functions) severe enough that the individual can no longer function independently at work or in society. There is no decrease in level of consciousness. Early in the illness, physical strength is maintained, though later the individual may "forget" how to perform certain physical functions, such as using tools or utensils, dressing, or performing personal hygiene activities. Onset of dementia may occur over days, months, or years. Its course may be static or progressive. Causes of dementia, other than AD, include other neurodegenerative disease, central nervous system infection, brain tumor, metabolic disease, vitamin deficiency, and cerebrovascular disease.

An Evolving Understanding of Dementia

Within three years of the publication of Dr. Alzheimer's first case, the term "Alzheimer's disease" was applied to patients who developed significant difficulty in memory and other areas of cognition at an age less than sixty-five years. Individuals who developed such symptoms later in life, generally after the age of sixty-five, were said to be suffering from senility, a process considered a normal part of aging. The phrase "hardening of the arteries," implying narrowing of arterial size with a reduction in blood flow to the brain, was used by physicians and by laypersons to designate the reason for senility. However, a causal relationship between arterial narrowing and senility had not been established scientifically.

Critical research reports were published in 1968 and 1970 providing evidence that senility and the disease Alzheimer described were similar both clinically and pathologically. Patients in each category developed similar and multiple cognitive deficits. Patients in each category developed plaques and tangles, and the majority of those diagnosed with senility did not have evidence of "hardening of the arteries." Over the next decade senile dementia, Alzheimer's type, would replace senility as the accepted common cause of late-life dementia.

In 1984, consensus criteria for a clinical diagnosis of AD were established. Cardinal features include the insidious onset of decline in at least two areas of cognition, gradual progression of severity in these spheres resulting in dementia, onset of symptoms between the ages of forty and ninety years (most often after age sixty-five), and absence of another medical condition that by itself could cause dementia. Pathological study of tissue after death should reveal the characteristic findings of senile plaques in age-associated numbers (numbers larger than expected for the individual's age) and of neurofibrillary tangles. Using these criteria, both Alzheimer's disease as a presenile disorder and senile dementia, Alzheimer type, are subsumed into the broader diagnosis, Alzheimer's disease.

Genetics of Alzheimer's Disease

There are three areas of evidence that indicate a genetic basis for AD. First, it occurs as a Mendelian, autosomal dominant disease of early onset (occurring before the age of sixty) in multiple families. However, the number of such families with autosomal dominant inheritance is small. Second, it is generally the case that if an individual has a first-degree relative (parent or sibling) with AD, he or she has a greater risk of developing the disease than a person with no affected first-degree relative. Finally, AD is more likely to occur in each of a pair of identical twins than it is to occur in a pair of fraternal twins.

Recognizing these observations, in the mid-1980s researchers initiated scientific efforts to identify genes of importance in the disease, using the then-emerging recombinant DNA technology. By 1995, three causative genes and one susceptibility gene had been identified: APP, PS1/2, and APOE.

APP.

In 1991, a British research group identified mutations in the APP gene that occurred only in patients with AD in very rare families. (Less than twenty such families have been reported in the medical literature.) The mutations were not found in family members who did not have AD. The APP gene codes for amyloid precursor protein, one of whose degradation products is a main constituent of the senile plaques of AD.

PS1 and PS2.

In 1992, using linkage analysis of data from early-onset, autosomal-dominant families, researchers in Seattle, Washington; Jacksonville, Florida; and Antwerp, Belgium, almost simultaneously determined

that a then-unknown gene for early-onset AD was located on chromosome 14. In 1995, a research scientist in Toronto, Canada, identified this gene as PS1, which codes for the protein called presenilin1. Individuals who have mutations in the gene consistently develop AD. Also in 1995, using comparative genomic techniques, the Seattle research group cited above identified the PS2 gene, which codes for the protein termed presenilin 2. Using data from a few large, genetically isolated families with early-and late-onset disease, they determined that mutations in the gene consistently occur only in patients with AD.

APP, PS1, and PS2 are causative genes: When mutated, each causes AD. If a person has a mutated gene, he or she will develop the disease at about the same age as others who have the same mutation. The risk of developing the disease approaches 100 percent.

APOE.

In 1993 researchers in Durham, North Carolina, reported that one form (allele) of the APOE gene occurred more commonly in patients with late onset AD than was expected given its occurrence in the population as a whole. Numerous additional research groups corroborated the finding. The APOE gene occurs in three forms (alleles), determined by the DNA sequence. The three forms are termed APOEε2, APOEε3, and APOEε4, and they code for apolipoprotein E molecules differing from one another by only one or two amino acids. APOE is a susceptibility gene; it imparts an increased risk of disease occurrence but by itself does not cause the disease. The presence of the ε4 form (APOEε4) in either one or two copies in an individual increases the likelihood that the individual will develop AD. Occurrence may depend on other genetic factors or environmental factors or some combination from each category.

Additional families exist with early-onset, autosomal-dominant AD with no APP, PS1, or PS2 mutations. Such families provide evidence that there may be additional causative genes. Whole-genome-scan analyses reported in the late 1990s provide evidence of additional susceptibility genes on chromosomes 9, 10, and 12. The genes located on these chromosomes have yet to be identified.

Rationale for a Genetic Approach to Alzheimer's Disease

Alzheimer's disease, broadly defined, is a complex genetic disorder: Multiple causative and susceptibility genes acting singly or in concert produce similar symptoms and pathologic changes in patients. In each of its forms, it manifests age-dependent penetrance, meaning that the older an individual becomes, the more likely it is that he or she will develop the disease. Disease manifestations (such as age of onset or rate of progression) may be influenced by environmental exposures (alcohol use, head injury) or other health conditions (such as cerebrovascular disease). Identification of AD genes will lead to a better understanding of the cellular processes that cause dementia.

Currently, amyloid production from amyloid precursor protein is the focus of much research, although debate continues about its role. Amyloid production and deposition in the brain are affected by each of the four known AD genes. Decrease in amyloid production or increase in amyloid metabolism with a resulting decrease in deposition may result in delayed age of onset or slower progression of disease. Thus, alteration of amyloid processing of sufficient magnitude might result in disease prevention. Once process-altering treatments become available, knowing who is at risk for the disease will be important.

Genetic Testing and Alzheimer's Disease

DNA testing can be performed to determine whether an individual has a mutation in one of the causative genes and/or whether he or she carries one or two copies of the APOEε4 susceptibility gene. Whether to test and which test to perform will depend on three conditions: family history of dementia, age of onset of disease, and clinical status of the individual. If a person has dementia, the test result could be useful in determining that the cause of the dementia is a form of AD. If a person has no symptoms of dementia, an estimate of the individual's risk could be developed, using the test. In the case of such estimates, both the actual accuracy of the test and the tested individual's understanding of its accuracy are of concern. While the consensus is that presymptomatic testing for causative mutations may be performed with appropriate counseling, debate over the safety and utility of APOE testing for individuals who do not show symptoms of Alzheimer's is ongoing.

In 2001, there was no treatment that prevented, much less cured, AD. Information regarding the risk of developing AD is useful only in life planning activities (such as purchasing or offering health insurance coverage or long-term care insurance coverage, or choosing retirement age) or in family planning. An individual's ability to cope with either an increased or a decreased risk may vary. Misuse of the information resulting in insurance or employment discrimination is possible. Absence of a causative gene mutation or of an APOEε4 susceptibility gene in either symptomatic or presymptomatic disease does not preclude AD as the cause of dementia or mean that the individual has no risk of developing AD in later years.

SEE ALSO COMPLEX TRAITS; DISEASE, GENETICS OF; GENE DISCOVERY; GENETIC TESTING; INHERITANCE PATTERNS; PSYCHIATRIC DISORDERS.

P. C. Gaskell Jr.

Bibliography

Mace, Nancy L., and Peter V. Rabins, eds. The 36-Hour Day, 3rd ed. Baltimore: The Johns Hopkins University Press, 1999.

St. George-Hyslop, Peter H. "Piecing Together Alzheimer's." Scientific American (Dec. 2000): 76-83.

Terry, Robert D., et al., eds. Alzheimer Disease, 3rd ed. Philadelphia, PA: Lippincott, Williams & Wilkins, 1999.

Internet Resources

"Ethical, Legal, and Social Issues." Human Genome Project, U.S. Department of Energy Office of Science. <http://www.ornl.gov/TechResources/Human_Genome/home.html>.

"Progress Report on Alzheimer's Disease, 1999." National Institute on Aging. Bethesda: National Institutes of Health, 1999. <http://www.nih.gov/nia/>.

The first preimplantation testing for the APP mutation was announced in February 2002. Four gene-negative embryos from a gene-positive woman were selected and implanted, and she gave birth to one child who was free of the gene mutation, which causes early-onset Alzheimer's disease.