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Relation of Histologic Markers to Dementia Severity, Age, Sex, and Apolipoprotein E Genotype

Leonard Berg, MD; Daniel W. McKeel, Jr, MD; J. Philip Miller; Martha Storandt, PhD; Eugene H. Rubin, MD, PhD; John C. Morris, MD; Jack Baty; Mary Coats, MSN; Joanne Norton, MSN; Alison M. Goate, DPhil; Joseph L. Price, PhD; Marla Gearing, PhD; Suzanne S. Mirra, MD; Ann M. Saunders, PhD

Arch Neurol. 1998;55:326-335.

Objective  To study differences between subjects with Alzheimer disease (AD) and cognitively intact control subjects, with respect to brain histologic markers of AD, and the relationship of those markers in the AD group to severity of dementia, age at death, sex, and apolipoprotein E genotype.

Setting  Washington University Alzheimer's Disease Research Center, St Louis, Mo.

Design and Subjects  Consecutive neuropathologic series of 224 prospectively studied volunteer research subjects, 186 with dementia of the Alzheimer type (DAT) or "incipient" DAT and confirmed to have AD by postmortem examination and 13 cognitively intact subjects, confirmed to lack postmortem findings of AD.

Main Outcome Measures  Brain densities (number per square millimeter) of senile plaques and neurofibrillary tangles, extent of cerebral amyloid angiopathy, cortical Lewy bodies, and apolipoprotein E genotype.

Results  Neocortical neurofibrillary tangle densities were substantially correlated with dementia severity, and to a greater degree than was true for senile plaque densities. When infarcts, hemorrhages, and Parkinson disease changes coexisted with AD, neurofibrillary tangle and senile plaque densities were lower. Plaque-predominant AD was found in a greater proportion of subjects with milder than more severe dementia. Entorhinal cortical Lewy bodies were no more frequent in plaque-predominant AD than in the remaining AD cases. Increasing age at death was negatively correlated with dementia severity and densities of senile plaques and neurofibrillary tangles. The apolipoprotein E 4 allele frequency was greater in AD than in control subjects but decreased with increasing age. After controlling for dementia severity, senile plaque densities were only weakly related to 4 allele frequency, and only in hippocampus. However, the degree of cerebral amyloid angiopathy was clearly related to 4 allele frequency. Among subjects diagnosed during life as having DAT or incipient DAT, only 7% were found to have a neuropathologic disorder other than AD causing their dementia.

Conclusions  (1) The order of the strength of relationships between densities of histologic markers and dementia severity in AD is neurofibrillary tangles greater than cored senile plaques greater than total senile plaques. (2) Advanced age at death is associated with somewhat less severe dementia and fewer senile plaques and neurofibrillary tangles. (3) Plaque-predominant AD may represent a developmental stage in AD. (4) Despite a substantial effect of apolipoprotein E 4 as a risk factor for AD, on decreasing the age at AD onset, and increasing the amount of cerebral amyloid angiopathy, its effect on senile plaque densities is variable and complex, being confounded with age, dementia severity, and methodologic differences. (5) Stringent clinical diagnostic criteria for DAT, even in the very mild stage, and senile plaque–based neuropathologic criteria for AD are highly accurate.

From the Alzheimer's Disease Centers of Washington University, St Louis, Mo (Drs Berg, McKeel, Storandt, Rubin, Morris, Goate, and Price, Messrs Miller and Baty, and Mss Coats and Norton); Emory University, Atlanta, Ga (Drs Gearing and Mirra); and Duke University, Durham, NC (Dr Saunders).

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