To what degree is late life cognitive decline driven by age-related neuropathologies?

Abstract

The ageing brain is vulnerable to a wide array of neuropathologies. Prior work estimated that the three most studied of these, Alzheimer's disease, infarcts, and Lewy bodies, account for ∼40% of the variation in late life cognitive decline. However, that estimate did not incorporate many other diseases that are now recognized as potent drivers of cognitive decline [e.g. limbic predominant age-related TDP-43 encephalopathy (LATE-NC), hippocampal sclerosis, other cerebrovascular conditions]. We examined the degree to which person-specific cognitive decline in old age is driven by a wide array of neuropathologies. Deceased participants (n = 1164) from two longitudinal clinical-pathological studies, the Rush Memory and Aging Project and Religious Orders Study, completed up to 24 annual evaluations including 17 cognitive performance tests and underwent brain autopsy. Neuropathological examinations provided 11 pathological indices, including markers of Alzheimer's disease, non- Alzheimer's disease neurodegenerative diseases (i.e. LATE-NC, hippocampal sclerosis, Lewy bodies), and cerebrovascular conditions (i.e. macroscopic infarcts, microinfarcts, cerebral amyloid angiopathy, atherosclerosis, and arteriolosclerosis). Mixed effects models examined the linear relation of pathological indices with global cognitive decline, and random change point models examined the relation of the pathological indices with the onset of terminal decline and rates of preterminal and terminal decline. Cognition declined an average of about 0.10 unit per year (estimate = -0.101, SE = 0.003, P < 0.001) with considerable heterogeneity in rates of decline (variance estimate for the person-specific slope of decline was 0.0094, P < 0.001). When considered separately, 10 of 11 pathological indices were associated with faster decline and accounted for between 2% and 34% of the variation in decline, respectively. When considered simultaneously, the 11 pathological indices together accounted for 43% of the variation in decline; Alzheimer's disease-related indices accounted for 30-36% of the variation, non-Alzheimer's disease neurodegenerative indices 4-10%, and cerebrovascular indices 3-8%. Finally, the 11 pathological indices combined accounted for less than a third of the variation in the onset of terminal decline (28%) and rates of preterminal (32%) and terminal decline (19%). Although age-related neuropathologies account for a large proportion of the variation in late life cognitive decline, considerable variation remains unexplained even after considering a wide array of neuropathologies. These findings highlight the complexity of cognitive ageing and have important implications for the ongoing effort to develop effective therapeutics and identify novel treatment targets.

Keywords: Alzheimer's disease; cognitive ageing; dementia; neuropathology; vascular.

Figure 1

Spaghetti plot of individual‘ trajectories from a random sample of subjects (n = 50, left) and mean slope of cognitive decline superimposed on their estimated individual slopes (model-derived slopes, right).

Figure 2

Contributions of‘ combinations of the pathological indices to cognitive decline (model derived slopes). Alzheimer’s disease (AD) = neurodegenerative pathologies related to Alzheimer’s disease, i.e. global Alzheimer’s disease pathology, amyloid-β and PHFtau tangles; CVD = cerebrovascular diseases, i.e. gross infarcts, microscopic infarcts, atherosclerosis, arteriolosclerosis, cerebral amyloid-β angiopathy; non-Alzheimer’s disease (non-AD) = neurodegenerative pathologies, i.e. Lewy bodies, hippocampal sclerosis and LATE-NC.

Figure 3

Variation in cognitive‘ decline explained by the pathological indices (dark grey) and the residual, unexplained variation in cognitive decline (light grey) derived from fully adjusted models. Alzheimer’s disease (AD) = neurodegenerative pathologies related to Alzheimer’s disease, i.e. global Alzheimer’s disease pathology, amyloid-β and PHFtau tangles; CVD = cerebrovascular indices, i.e. gross infarcts, microscopic infarcts, atherosclerosis, arteriolosclerosis, cerebral amyloid-β angiopathy; non-Alzheimer’s disease (non-AD) = neurodegenerative pathologies, i.e. Lewy bodies, hippocampal sclerosis and LATE-NC.