“The Big Four” dementias – AD, LBD, FTD, and Vascular

There’s a wonderful article in the November/December 2009 issue of Neurology Now magazine.  It features Jerome and Renata Rafferty; Jerome had Lewy Body Dementia and Renata was his caregiver.

The “Other” Dementias (featuring Lewy Body Dementia story)

A companion article is titled “The Big Four.”  It gives short descriptions of four types of dementia – Alzheimer’s, Lewy Body Dementia, Frontotemporal Dementia, and Vascular Dementia.  The article notes that there are over 100 types of dementia.

Below the full text of the article, and a link to it online. You can also download the PDF of the article.

Robin
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journals.lww.com/neurologynow/Fulltext/2009/05060/The__Other__Dementias.14.aspx –> HTML version

The Big Four
Neurology Now
November/December 2009 – Volume 5 – Issue 6 – p 26-27,31-34

More than 100 types of dementia have been found, but four of them account for nearly 98 percent of all cases of dementia in the United States.

ALZHEIMER’S DISEASE (AD)

DESCRIPTION: People with AD develop memory problems, often followed by confusion, apathy, depression, emotional volatility, and other problems.

CAUSE: People with AD develop two types of dysfunctional protein in the hippocampus, the part of the brain essential for creating new memories. Tau protein accumulates within neurons in that region, while clumps of amyloid protein develop between neurons in that region. Some researchers, however, suspect that the toxic proteins may be the result of the disease rather than the cause.

TYPICAL CASE: The first symptom of AD almost always involves memory problems, such as forgetting familiar names and misplacing items. As the disease progresses people may have trouble finding their way home or keeping up with routine obligations such as doctor appointments, paying bills, and preparing meals. Later stages may affect the frontal lobes, resulting in erratic emotions, loss of normal inhibition, and hallucinations.

TREATMENT: Since AD results in decreased levels of acetylcholine, a neurotransmitter essential for memory and learning, drugs that boost acetylcholine, such as donepezil and memantine, often help, at least for a while. Other treatments are available for specific symptoms such as depression, hallucinations, and movement disorders, but nothing seems to slow development of the disease.

ON THE HORIZON: Several drugs and vaccines designed to inhibit the production of toxic tau and amyloid protein, or remove it once it appears, are in development. However, people who have tried the drug experimentally failed to improve significantly, even though protein levels declined, sometimes dramatically.

LEWY BODY DEMENTIA (LBD)

DESCRIPTION: Like Alzheimer’s, LBD produces cognitive decline, but with three additional traits. Instead of declining continuously, people with LBD tend to fluctuate in terms of attention, alertness, ability to speak coherently, and other symptoms. They also tend to have visual hallucinations, often benign. Finally, they tend to develop symptoms of Parkinson’s disease, including rigidity, tremor, and slowness of movement.

CAUSE: A type of protein known as alpha-synuclein clumps into Lewy bodies, which appear inside of cells, or neurons. Lewy bodies may result from the inability of the cell to break down and recycle alpha-synuclein efficiently. As the protein accumulates, it sticks together, as though the cell is trying to gather its own debris to keep it out of the way.

TYPICAL CASE: People with LBD often act out violent dreams that involve being pursued or attacked. They may develop benign hallucinations involving, for example, children or animals running around the house. Attention and concentration may fluctuate, and patients may start to have trouble with visual-spatial abilities-they may misjudge the height of a step or miss a cup when they reach for it. Some people with LBD experience an overwhelming urge to sleep during the day. Their movements also may become rigid and slow, like the symptoms of Parkinson’s disease, and they may develop problems with memory, judgment, and mood, like the symptoms of AD.

TREATMENT: No treatment specifically for LBD exists. However, since LBD affects nearly every neurochemical system in the brain, specific aspects of the disease can be treated. Memory problems can be treated with donepezil and other drugs for AD. Movement disorders may respond to L-dopa and other medications for Parkinson’s disease. Modafinil may alleviate daytime sleepiness.

ON THE HORIZON: No drug yet exists that affects the synuclein protein, although some drugs exist for daytime sleepiness, and another, which resembles methylfenidate, is in development.

FRONTOTEMPORAL DEMENTIA (FTD)

DESCRIPTION: FTD includes several disorders that cause the frontal lobes behind the forehead, and the temporal lobes at the sides of the brain, to atrophy and shrink. Patients either develop speech difficulties, known as aphasia, or they display inappropriate social behavior. Aphasia may involve halting, effortful speech with the patient struggling to produce the right word. Behavioral changes may involve indifference to the concerns of others. Some patients developing FTD may start shoplifting or become attracted to shiny objects or fire.

CAUSE: In FTD, a protein known as TDP-43 accumulates within cells at the front of the brain. In one form of FTD known as Pick’s disease, tau protein, found in the hippocampus of people with AD, accumulates within cells in the frontal lobes.

TYPICAL CASE: A person developing FTD generally exhibits personality or mood changes. An outgoing person may become withdrawn and depressed, while an introverted person may become loud and outgoing. Socially inappropriate behavior may also become more common. Later, FTD patients may develop speech difficulties as they lose the ability to recall the meaning of words, or they may start to speak with great fluency while making no sense.

TREATMENT: Only symptomatic treatments are available with medications developed for other disorders, such as psychiatric medications for behavioral problems or mood disorders. There are no treatments for language problems.

ON THE HORIZON: Methylene blue, a drug in development for AD, inhibits the aggregation of tau protein, so it may help patients with Pick’s disease. Another tau aggregation inhibitor known as AL-108, or davunetide, is in clinical trials, and may soon become the first tau-active drug available in the U.S. TDP-43, the offending protein in other forms of FTD, was discovered only three years ago, leaving little time for the development of effective treatments.

VASCULAR DEMENTIA

DESCRIPTION: Since this dementia results from several small strokes, and strokes can affect any part of the brain, the symptoms of vascular can vary widely. However, they usually include declines in problem-solving ability, memory, and socially appropriate behavior.

CAUSE: Vascular dementia is believed to result from damage to brain cells caused by lack of oxygen when the blood supply is cut during a series of mild strokes. However, one study of 1,000 brains from demented patients who had died found only six that had pure vascular dementia, with the slow progression typical of the disorder. The rest also had another form of dementia.

TYPICAL CASE: To be diagnosed with vascular dementia, a patient must show evidence of a stroke in a location that could affect cognition, and cognitive problems must develop within three to six months of the stroke. A patient who meets these criteria may develop memory problems and have trouble speaking coherently or understanding the speech of others. They may also develop motor difficulties that prevent them from dressing themselves.

TREATMENT: The first goal is to reduce stroke risk by improving cardiovascular health. Statins may be prescribed to lower cholesterol, anti-hypertensives to lower blood pressure, and omega-3 pills to improve triglyceride levels. Low-dose aspirin may be prescribed to inhibit the clotting of the blood, and patients may be urged to give up smoking and drinking and reduce stress.

ON THE HORIZON: Damage from strokes cannot be reversed, but the brain can compensate for some deficits. Physical therapy designed to stimulate brain plasticity may provide some help.

Copyright © 2009, AAN Enterprises, Inc.

Famous amnesic launches a bold, new brain project at UCSD’s Brain Observatory

This post is likely only of interest to those curious about brain tissue analysis. I’ve been watching the slicing of this brain tissue today at UCSD’s Brain Observatory, and agree that it’s “mesmerizing.” The process will produce about 2500 tissue samples for analysis.

Here’s the live video:
http://thebrainobservatory.ucsd.edu/hm_live.php

In the New York Times article from yesterday on this “famous brain” — http://www.nytimes.com/2009/12/03/healt … brain.html — a researcher said “It’s just amazing that this one patient — this one person — would contribute so much historically to the early study of memory.”

And here’s a good article on the Brain Observatory and the analysis of this particular brain from Monday’s San Diego Union-Tribune newspaper. For me, the last two sections of the article were the most interesting (starting with “The Brain Observatory is divided between…”).

http://www3.signonsandiego.com/news/200 … ld-new-br/

H.M. recollected
Famous amnesic launches a bold, new brain project at UCSD

By Scott LaFee, San Diego Union-Tribune Staff Writer
Monday, November 30, 2009 at 12:04 a.m.

As best he could remember, Henry Gustav Molaison never visited San Diego, spending his entire life on the East Coast. When he died late last year at the age of 82, Molaison was a man almost entirely unknown except by his initials H.M. and the fact that experimental brain surgery had erased his ability to form new memories.

He forgot names, places, events and faces almost immediately. Half an hour after lunch, he couldn’t recall what he had eaten, or that he had eaten at all. His face in the mirror was a constant surprise because he remembered only what he looked like as a young man. Every question was new, even those asked just minutes before.

Yet Molaison bore this strange and unimaginable burden with grace and stoicism, allowing scores of scientists to study, probe and ponder his condition for decades, each seeking to better understand the mysteries of the human brain, memory and personal identity.

“H.M. started a revolution in the study of memory,” said Dr. Vilayanur S. Ramachandran, a professor of psychology and neuroscience and director of the Center for Brain and Cognition at UCSD at the time of Molaison’s death. “His was an unforgettable contribution.”

Molaison died of respiratory failure on Dec. 2, 2008, but his story — and his legacy — does not end in that Connecticut nursing home. Within hours of death, Molaison’s brain would be scanned, removed and placed in the preservative formalin, the first steps on a journey to San Diego and a new kind of immortality.

On a cold night in mid-February, Jacopo Annese returned to San Diego, arriving on Jet Blue Flight 411 from Boston. With him was the brain of H.M. They had flown coach: Annese in the aisle seat, H.M.’s brain in a 19-quart white plastic cooler strapped next to him in the window seat. More than a few fellow travelers looked curiously at the arrangement; some inquired directly.

“I tried not to be coy,” said Annese. “I told them the cooler contained a very important scientific specimen. I didn’t say a brain. I didn’t want to risk upsetting any passengers.”

Sophisticated and articulate, educated and trained in Italy, England and the United States, the 43-year-old Annese came to the University of California San Diego in 2005 to develop and direct the Brain Observatory, with an ambitious plan to create a new and unrivaled collection of human brains for scientific study.

These brains, normal and with various pathologies, will be preserved on thousands of slides that, in turn, are converted into extraordinarily high-resolution digital images freely available online. Researchers around the world will be able to use the material to conduct investigations ranging from parsing basic cognitive functions or the physical effects of diseases like Alzheimer’s to more abstract inquiries such as how memories are created and changed and the organic nature of consciousness.

The project has already begun with a handful of brains. Annese envisions the collection as a kind of library, each brain containing a life story. “We strive to treat the brains we study not as anonymous tissue, but as representations of a person and of a mind. We want to write books about people’s lives, neurological biographies that survive in glass and pixels.”

In this most novel of libraries, Molaison’s brain is the rarest of volumes. He is the most famous amnesic of all time, perhaps the most-studied neurological patient in history.

When he was 10 years old, Molaison began suffering epileptic seizures and blackouts, which increased in severity and frequency until, in his 20s, he was no longer able to work or live alone. In 1953 at the age of 27, Molaison agreed to undergo a radical experimental operation intended to relieve his suffering. Dr. William Beecher Scoville, a noted neurosurgeon at Hartford Hospital in Connecticut who had refined many of the techniques used in lobotomies, suctioned out finger-sized portions of the temporal lobes on both sides of his brain. The removed tissue contained most of Molaison’s hippocampus, a brain region whose function was poorly understood at the time, if at all.

The seizures largely stopped, but so too did Molaison’s ability to form new memories, though he could recall parts of his life before the surgery, a condition called severe anterograde amnesia. Scoville and a Canadian psychologist named Brenda Milner quickly realized that Molaison represented a tragic but rare opportunity to explore how human memory works.

With Molaison serving as willing and genial subject, identified only as H.M. to protect his privacy, they began a series of studies. In a landmark 1957 paper, Scoville and Milner described H.M.’s bifurcated memory for the first time. The paper, which has been cited by other researchers almost 2,000 times, led to the startling realization that memory is not a generalized brain function, but rather is controlled by key regions like the hippocampus, which regulates the flow of information destined to become long-term memory.

In many ways, H.M. appeared to be an ordinary fellow. He liked crossword puzzles and watching TV. He was polite, funny and self-effacing. “He was a very endearing person,” said Annese, who met H.M. once in 2006 during early planning for the Brain Observatory and library. “I was happy to get to know the man.”

Surprisingly, even with no ability to form long-term memories, H.M. could learn new things, in particular new muscle memory skills like drawing or playing golf. He didn’t remember taking lessons or practicing, but the acquired abilities stuck.

That discovery generated another new and fundamental insight into human cognitive function. There are different types of memories: Long-term declarative memories, which H.M. could no longer form; short-term memories which H.M. still possessed to a degree; and motor memories, such as recalling how to ride a bike, which H.M. never lost.

Each kind of memory, scientists deduced, must essentially be created and reside in different parts of the brain. Sometimes H.M. learned and remembered things that happened post-surgery, such as the assassination of John F. Kennedy in 1963. This suggested portions of H.M.’s memory system survived his 1953 surgery or that other regions had taken up some of those duties. No one really knew.

To really understand what was going on inside H.M.’s head, researchers needed to venture more deeply inside the brain itself.

The Brain Observatory is divided between an elaborately equipped wet lab for handling flesh-and-blood brains, and separate areas housing high-powered microscopes and computers for digitizing them.

Converting biology to bytes takes time. It is complex, painstaking and fraught with unprecedented technical challenges. A brain like H.M.’s represents a singular chance to advance scientific knowledge, but there is almost no room for mistakes.

“It’s a huge responsibility that many labs might not want,” said Annese.

Within four hours of his death, Molaison’s body was moved to Massachusetts General Hospital (MGH), where researchers, led by Suzanne Corkin, a professor of behavioral neuroscience at the Massachusetts Institute of Technology who had worked with H.M. for 46 years, conducted an overnight series of magnetic resonance imaging scans, a last chance to record his brain’s structure and condition “in situ.”

The next morning, after Annese had flown overnight to get there, he and MGH neuropathologist Matthew Frosch delicately removed H.M.’s brain from his skull.

“I was sweating bullets,” Annese later told the journal Science.

Like all fresh brains, H.M.’s had the consistency of Jell-O. It could be easily damaged, harm that might render it less useful — perhaps even useless — for further study. But the removal went smoothly and the brain was immediately deposited in formalin, suspended by a string so that it wouldn’t become deformed by resting on the bottom of the container. It would remain in formalin for two months until firm enough to travel safely to San Diego.

After returning in February with the brain, Annese conducted a second, more exhaustive series of MRI scans over two days, producing a more comprehensive anatomical map and a final record of the brain intact.

Next, the brain was immersed for weeks in increasing levels of sucrose solution. As the sucrose (sugar) infused the brain, it replaced water in cells, reducing the risk that ice crystals might later form, which could cause tissue to tear and reduce the brain’s research value.

High-security freezers house the project’s brains. (Annese has 10 so far.) The freezers are constantly and continuously monitored, with emergency backup power and an automatic alert system.

H.M.’s brain is scheduled to be sectioned on Wednesday, with segments of the procedure broadcast live via the Brain Observatory’s Web site (thebrainobservatory.ucsd.edu). Annese has been practicing the procedure on control brains.

Just prior to cutting, H.M.’s brain will be dipped in a liquid bath of isopentane at minus 40 degrees Celsius until frozen solid. The actual slicing is reminiscent of a delicatessen. The prepared brain is locked inside a cuff containing circulating ethanol to keep it precisely frozen. Too cold and the tissue might shatter during cutting; too warm and the tissue becomes sloppy. The cuff and brain are then mounted atop a commercial microtome modified by Annese with help from machinists at the Scripps Institution of Oceanography. Every component has been meticulously measured and engineered. A razor-sharp blade of tempered steel glides over the exposed brain, cutting from the front of the brain to the back, producing opaque, whitish slices that crinkle and wad on the blade’s edge like slivers of cut ginger.

Each brain slice is approximately 70 microns thick, about the width of a hair. An average-sized brain produces 2,600 to 3,000 such slices. Once the cutting begins, it continues until the brain is completely sectioned, a 30-hour endeavor.

A camera mounted above methodically records every slice, though a human operator must constantly attend to gently dab up each crumpled slice off the blade and deposit it into a sequentially numbered container filled with buffer solution.

“There’s something mesmerizing about doing this,” said Natalie Schenker, a postdoctoral research associate as she dabbed and deposited slices of control brain. “It’s like going on a journey, each slice getting you to another place in the brain.”

The majority of slices will be left untouched, cryogenically preserved for future experiments. Some slices, perhaps every 30th to 50th, will be mounted on postcard-sized glass slides. Mounting is an exacting process. A technician uses fine arts brushes to tease a wadded slice floating in a tray of buffer solution to lie flat upon an underlying slide, a physical match to the photo taken of that same slice during the cutting procedure. One mounting can take up to an hour.

The slides are then dried and some sequentially stained, what Annese calls “the club sandwich idea.” Different stain colors reveal different components of the brain. Blue shows individual neurons; brown highlights myelin-coated connective structures and support cells.

Finally, the slides are ready to be digitized. Each is placed under a microscope at 20X magnification to distinguish individual cell types. A computerized camera next begins snapping pictures of the microscopic scene. It requires 20,000 such “capture tiles” to produce a mosaic of just one slide, enough digital information to fill 200 DVDs.

Annese and colleagues have designed an automated system to do this demanding but tedious work. The data are sent to UCSD’s California Institute for Telecommunications and Information Technology (Calit2) and the San Diego Supercomputer Center, where it will be managed and stored for future use.

A fully sliced, mounted, stained and digitized brain is, in some ways, a return to wholeness, a brain reassembled in cyberspace. “We’re taking all of the two-dimensional image data (from the slides) and reconstructing them in a 3-D system,” said Alain Pitiot, a computer scientist at the University of Nottingham in England. “We’re reforming the brain so that researchers can see things in context.”

The intended result will be a bit like Google Earth. Scientists will be able to zoom in and out of a digitized brain; focusing down to the level of individual neurons or pulling back to examine whole brain circuits or regions.

When fully up and operating, the project will be an interactive affair. All data will be online and open to viewing and discussion. Neuroscientists will be able to watch procedures, make recommendations and observations, suggest experiments or request tissue samples. Nonscientists will have similar, if more limited, access.

For obvious reasons, H.M.’s brain holds special interest. It’s the catalyst for the entire endeavor. But more importantly, researchers are eager to compare what they learned about Molaison while he was alive with what they can discover in his digitally revealed brain.

“The extraordinary value of H.M.’s brain is that we have roughly 50 years of behavioral data, including measures of different kinds of memory as well as other cognitive functions and even sensory and motor functions,” said Corkin at MIT.

“We know what he was able to do and not do. Our goal is to link his deficits to damaged brain areas and his preserved functions to spared areas.”

H.M.’s brain will also be compared with those of other amnesic patients. Larry Squire, a professor of psychiatry and neurosciences at UCSD, has donated the brains of three much-studied patients. Some of Ramachandran’s patients have also agreed to donate their brains after death.

But the Brain Observatory and library project is about more that just H.M. and the mystery of memory. It promises the chance to investigate all things that ail the brain. For example, Annese is already processing brains that are part of an HIV study. And he has established partnerships with Lifesharing and the San Diego Eye Bank, which handle organ and tissue donations in San Diego County, to secure new donors.

Annese is quick to note that he’s not solely interested in afflicted or particular brains. He hopes people who have no known neurological issues will donate their brains to the Observatory, too.

“Healthy brains for study are very rare, but they are essential if we want to understand how brains age and why some people avoid neurological disease and dysfunction. We want to know what a normal brain is.”

But more profoundly, Annese hopes the Observatory and the future research that flows through and out of it will help answer the enduring question of what exactly makes each of us human and unique.

“We know that the human brain has a basic pattern,” said Annese. “We’re all born with the same kind of instrument, let’s say a violin. But how we play this violin and what we decide to play shapes this instrument during our lives. We can learn a lot by the wear-and-tear of life on our violins, how each of us has modified it. These could prove to be anatomical fingerprints of individuality, biological clues of what makes us who we are.”

OBSERVING LIVING DONORS IS PART OF STUDY

The Brain Observatory and its related brain library project will necessarily rely upon donated brains, primarily through the services of two regional organ and tissue banks, Lifesharing and the San Diego Eye Bank.

Much of the emphasis will be on finding donors who are able to participate in a monitoring, data-gathering program while they are still alive and well, people like Clint and Maggie Spangler.

The La Jolla couple is reasonably healthy. “I’m told I have the brain of a 60-year-old,” said Clint, who is 81. Nonetheless, he and his wife both suffer from essential tremor, a progressive neurological condition characterized by uncontrollable trembling, typically of the hands though it can affect many parts of the body.

Often confused with Parkinson’s disease, essential tremor is not life-threatening. “It’s more of a nuisance,” said Maggie. But it is common. According to the National Institutes of Health, the condition affects up to 14 percent of Americans over the age of 65.

The exact cause of essential tremor is not known, but there’s a clear genetic component. Two of the Spangler’s four children have the condition; a third appears likely to develop it. Clint and Maggie have promised their brains to the observatory, hoping that the donations might help researchers solve their condition and others.

“We’re not too philosophical about it,” said Maggie. “We’d like to be able to help, and we’re certainly not going to need our brains after we’re dead. Besides, do you know what a funeral costs these days?”

To learn more about organ and tissue donations, visit Lifesharing at lifesharing.org or the San Diego Eye Bank at sdeb.org

Correlations between language problems and brain pathology

This is an interesting French study correlating clinical symptoms related to language and speech with the pathology seen in autopsied brain tissue. Eighteen patients were monitored over a 15-year period. Four patients developed right-predominant corticobasal syndrome. One patient was given a clinical diagnosis of PSP.

“Of the 18 cases, 8 had FTLD-TDP, 3 had AD, 2 had PSP, 2 had CBD, 2 had PiD, and 1 had AGD,” upon brain autopsy. Of the two who had confirmed PSP diagnoses, one was diagnosed with the behavioral variant of FTD during life though the diagnosis was later changed to PSP when supranuclear palsy appeared. The other was diagnosed with corticobasal syndrome during life.

Of the four patients diagnosed with corticobasal syndrome during life, one had PSP upon brain autopsy, one had CBD, one had Pick’s Disease, and one had FTLD-TDP.

Of the two cases who had confirmed CBD diagnoses, one was diagnosed with FTDbv during life and the other with CBS during life.

The five patients who stopped speaking (“progressive anarthria”) all had tau pathology — either PSP, CBD, or Pick disease. (“[All] progressed to mutism, swallowing difficulties, and orofacial apraxia.”)

Findings of atrophy (on a CT or MRI) and findings of hypometabolism (on a SPECT) in nearly all of the the cases are provided along with info such as disease duration, MMSE score, Frontotemporal Behavior Scale rating, and Dementia Rating Scale score.

Eighteen patients is a very small study. We’ll have to see if the results can be replicated.

Robin

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Neurology. 2009 Nov 25. [Epub ahead of print]

Prediction of pathology in primary progressive language and speech disorders.

Deramecourt V, Lebert F, Debachy B, Mackowiak-Cordoliani MA, Bombois S, Kerdraon O, Buée L, Maurage CA, Pasquier F.
From the Memory Clinic (V.D., F.L., B.D., M.A.M.-C., S.B., F.P.) and Department of Neuropathology (O.K., C.-A.M.), CHU-Lille, Lille; University Lille Nord de France (V.D., F.L., B.D., M.A.M.-C., S.B., O.K., L.B., C.-A.M., F.P.), Lille; and INSERM (O.K., L.B., C.-A.M.), JP Aubert Research Centre, Lille, France.

OBJECTIVE: Frontotemporal lobar degeneration (FTLD) encompasses a variety of clinicopathologic entities. The antemortem prediction of the underlying pathologic lesions is reputed to be difficult.

This study sought to characterize correlations between 1) the different clinical variants of primary progressive language and speech disorders and 2) the pathologic diagnosis.

METHODS: The latter was available for 18 patients having been prospectively monitored in the Lille Memory Clinic (France) between 1993 and 2008.

RESULTS: The patients were diagnosed with progressive anarthria (n = 5), agrammatic progressive aphasia (n = 6), logopenic progressive aphasia (n = 1), progressive jargon aphasia (n = 2), typical semantic dementia (n = 2), and atypical semantic dementia (n = 2).

All patients with progressive anarthria had a tau pathology at postmortem evaluation: progressive supranuclear palsy (n = 2), Pick disease (n = 2), and corticobasal degeneration (n = 1).

All patients with agrammatic primary progressive aphasia had TDP-43-positive FTLD (FTLD-TDP).

The patients with logopenic progressive aphasia and progressive jargon aphasia had Alzheimer disease.

Both cases of typical semantic dementia had FTLD-TDP.

The patients with atypical semantic dementia had tau pathologies: argyrophilic grain disease and corticobasal degeneration.

CONCLUSIONS: The different anatomic distribution of the pathologic lesions could explain these results: opercular and subcortical regions in tau pathologies with progressive anarthria, the left frontotemporal cortex in TDP-43-positive frontotemporal lobar degeneration (FTLD-TDP) with agrammatic progressive aphasia, the bilateral lateral and anterior temporal cortex in FTLD-TDP or argyrophilic grain disease with semantic dementia, and the left parietotemporal cortex in Alzheimer disease with logopenic progressive aphasia or jargon aphasia. These correlations have to be confirmed in larger series.

PubMed ID#: 19940270 (see pubmed.gov for abstract only)

Robin’s note: I suggest looking up terms in wikipedia.

Symptoms of clinical intolerance during an acute levodopa challenge in relation to MSA

In this interesting research out of Argentina, the authors conclude that “symptoms of clinical intolerance during an acute levodopa challenge do not appear to be useful in the diagnosis of” multiple system atrophy (MSA).  The idea was to give patients levodopa (one brand name is Sinemet) to learn if they could differentiate between those with MSA and those with Parkinson’s Disease.  “Clinical intolerance” means nausea, vomiting, hypotension, and profuse perspiration.

The abstract is copied below.

Robin

——————-

Int J Neurosci. 2009;119(12):2257-61.

Does clinical intolerance to a diagnostic acute levodopa challenge differentiate multiple system atrophy from pd?

Estévez S, Perez-Lloret S, Merello M.
Movement Disorders Section, Raúl Carrea Institute for Neurological Research (FLENI), Buenos Aires, Argentina.

BACKGROUND: The diagnosis of multiple system atrophy (MSA) remains challenging.

OBJECTIVE: To determine if the occurrence of symptoms of clinical intolerance such as nausea, vomiting, hypotension, and profuse perspiration during a standard acute levodopa challenge may be a useful marker of MSA.

METHODS: A total of 507 dopaminergic acute challenge tests performed for different purposes in the last 10 years in a movement disorders clinic were reviewed, identifying patients who manifested symptoms of clinical intolerance during test performance. Only those tests completed for diagnostic purposes were included and these were matched by the presence or absence of response to levodopa, sex, and age, with a group of patients undergoing acute challenge without any symptoms of clinical intolerance. Presumptive diagnosis for each patient was performed by means of accepted clinical criteria after a significant follow-up period. Only patients with a final diagnosis of Parkinson’s disease (PD) or MSA were analyzed.

RESULTS: Twenty-three out of the 507 patients (women: 50%) presented symptoms of clinical intolerance and received a final diagnosis of PD or MSA, and underwent further analysis. Four out the 23 patients with intolerance (17%) and one out the 16 patients from the control group (6%) were diagnosed as having MSA (Chi-square = 1.05, p = .3). Overall sensitivity and specificity of the presence of clinical intolerance to predict diagnosis of MSA were 80% (95%IC: 45%-100%) and 44% (95%CI: 27%-61%) respectively.

CONCLUSIONS: Symptoms of clinical intolerance during an acute levodopa challenge do not appear to be useful in the diagnosis of MSA.

PubMed ID #: 19916854  (see pubmed.gov for this abstract only)

PSP Research Update – Notes from Golbe Webinar (11/19/09)

I don’t know how many listened to tonight’s CurePSP webinar. Though it had been advertised as “PSP, CBD and MSA – Research for Dummies,” Dr. Golbe’s title slide made clear he was talking only about PSP. There was significant overlap with the last webinar (with Dr. Bordelon and Dr. Schellenberg) but I didn’t mind. I always like listening to Dr. Golbe because he is one of the top PSP experts in the world. Further, his explanations of complex topics are very clear.

I also appreciated the fact that all the CurePSP messages (from various staff members and Board members) were gone, and that the webinar was not pre-recorded. And I liked how the questions were handled this time around. (I do wish that we could improve the editing or even consider eliminating some of the duplicate questions that get asked at each webinar.)

I was rather busy typing notes and didn’t get a chance to ask any questions myself. And, when tonight’s moderator Kate was speaking, I couldn’t hear her so I missed a few of those questions.

Here are my notes from Dr. Golbe’s presentation, with a few comments of my own. (I’ve added headings.)

Robin

————

Topic – PSP Research for Dummies

Presenter – Lawrence Golbe, MD
Prof of Neurology, UMDNJ-Robert Wood Johnson Medical School, New Brunswick, NJ
Dir of Research and Clinical Affairs, CurePSP

The “for dummies” books are written for intelligent people. That’s how the talk is geared.

Most research in PSP is pretty molecular.

PSP SYMPTOMS

What does PSP stand for?
Progressive = tends to worsen with time
Supranuclear = not primarily in the “nuclei” (clusters of brain cells in the brain stem that control eye movement), but at higher (“supranuclear”) brain centers
Palsy = poor movement (in the case of the eyes)

Main features of PSP:
* balance: especially unheralded falls; 2/3 of people have this problem
* speech (“dysarthria”): these problems happen usually later in the disease; spastic speech; hypophonia can occur; ataxic speech – sounds like you are drunk
* swallowing: pneumonia is possible; the problem is with liquids (which is the hallmark of neurological disorders); gap in the seal between the throat and the windpipe
* slow movement (“bradykinesia”) and slow thought: parkinsonian symptom
* insufficient movement: person just sits there, without moving
* eye movement: sophisticated neurologist who knows how to look for this can detect this problem at even early stages; the issue is both up and down gaze, but especially down gaze
* “frontal” behavior: problems with prioritizing, abstraction, inhibiting behavior. With “frontal” behavior, people with PSP have serious complications given the balance problem and the swallowing problem. Those with PSP stuff their mouths. Those with PSP get up to

Balance:
* usually the first symptom
* irregular gait. Often a drunken gait.

Bradykinesia (slow, insufficient movement):
* resembles Parkinson’s disease
* some of it is actually “rigidity” or muscle stiffness (face, neck)
* makes it difficult to compensate for balance problem

Dysarthria:
* ataxic: irregular bursts of speech
* spastic: strained quality
* hypophonic: low volume
* PSP usually has at least two of these three speech problems
* can have constant “growling.” “Frontal” behavior symptom.

Dysphagia:
* first and worse with thin liquids
* aspiration common
* large piece of food in windpipe is not usually the problem

TAU

Tau protein acts as scaffolding:
* Tau microtubules stabilize the structure of brain cells (and the axon) and serve as “railroad tracks.”
* In PSP, tau protein isn’t working right. The cell breaks down, and stops working properly.*
* Neurofibrillary tangles (NFTs): hallmark of PSP in the brain
* What’s the chicken and what’s the egg? Do the tangled clumps of tau proteins serve a useful purpose? Probably just getting rid of the tangles won’t solve PSP.

CAUSES OF PSP – GENETICS

Is PSP inherited?
Very weakly hereditary: only about 1 in 100 patients has a relative with PSP

Intro to the H1 Haplotype:
H1 haplotype is the genetic marker for PSP. A haplotype is a string of genetic markers on a chromosome. In the case of PSP, this haplotype is on chromosome 17. This haplotype signals the presence of disease-causing mutation in or near that region.

H1 Haplotype (% of chromosomes in those with PSP): (Houlden et al, 2001)
H1: 94% of (chromosomes in those with) PSP; 92% of CBD; 77% of control
H2: 6% PSP; 8% CBD; 23% control
So…PSP has an over-representation of the H1 haplotype.
Could it be that the H2 haplotype is protective?

H1/H1 Genotype (% of individuals): (Houlden et al, 2001)
H1/H1: 88% (of individuals with) PSP, 84% CBD, 60% control
H1/H2: 12% PSP, 16% CBD, 34% control
H2/H2: 0 PSP, 0 CBD, 7% control
H1/H1 = getting an H1 haplotype from each parent

Tau alternative splicing: (Hardy)
There are four exons that have the code for microtubule binding.
In normal brains: 1:1 ratio of 3 repeat tau protein isoforms and 4 repeat tau protein isoforms
In PSP: 4 repeat tau is abnormally abundant

Tau isoforms expressed in NFTs in various disorders:
Mostly 4 repeat tau disorders: PSP, CBD, FTD with exon 10 mutations, Guadeloupean parkinsonism, AGD
Mostly 3 repeat tau disorders: Pick’s disease, myotonic dystrophy
3 and 4 tau equally: AD, FTD without exon 10 mutations, Parkinson-dementia complex of Guam, Postencephalitic parkinsonism

Conclusions:
* the H1/H1 genotype is nearly necessary but far from sufficient for PSP to develop
* PSP has an excess of 4-repeat tau protein, but the significance of that remains unclear
* one chromosome 17 with the H2 haplotype reduces PSP risk
* both chromosome 17s with the H2 haplotype reduce PSP risk even more
* what “conditions” the genetic effect?

MITOCHONDRIA

Mitochondrial Genetics in PSP:
* mitochondrion = energy factories of cells
* make energy from oxygen and sugar
* have their own genes kept apart from the cell’s main set of genes
* mitochondrial genes do not work properly in PSP, PD, AD, etc.
* it’s very hard to study mitochondrial genes. Is the function genetic or toxic?

CAUSES OF PSP – ENVIRONMENT

Cause of PSP: Environment?
* Not well-studied at all
* Dr. Litvan is studying this now
* Those with PSP are less well-educated. May mean more industrial exposure or exposure to toxins? (Dr. Golbe published a study about 20 years ago. A French study just published last month found the same thing: less well-educated.)
* Not a consistent finding: more farming. May mean more exposure to pesticides, fresh fruits/vegetables.
* Environmental toxins can damage mitochondria.

[Robin’s note: You can find the abstract of the French study posted here — http://forum.psp.org/viewtopic.php?t=8205 — or look it up on pubmed.gov using PubMed ID#19864660.]

CAUSES OF PSP – DIET

Cause of PSP: Diet?
* The just-published French study didn’t find anything diet-related.
* Guadeloupe cluster of PSP-like illness. Those with PSP-like disease on Guadeoupe have consumed more sweetsop and soursop fruit. This fruit has been found to harbor toxins that act on the mitochondria. (Caparros-Lefebvre et al, Lancet 1999) Mouse experiments are currently underway. Maybe we have something in our diet with a similar toxin? (You might see this fruit in a Jamaican restaurant.)
* Guam cluster of PSP-like illness. Dietary theory now discounted. Genetic theory being re-examined. Mainly one ethnic group on Guam who get this disease. The disease is dying out.

EXCITING DEVELOPMENTS IN PSP GENETICS

New, exciting developments in genetics of PSP:
* hereditary FTD-17 as a human genetic “model” of PSP. Mouse, fruit fly, zebrafish genetic models. These animals are given FTD-17. Convenient to study drugs in such animals.
* whole genome analysis produced four new (previously unsuspected) genetic factors (plus the tau gene) implicated in PSP. We are awaiting confirmation. If confirmed, the research should be published in early 2010. This analysis will suggest new biochemical pathways and drug targets.

MEDICATIONS AND TREATMENT FOR PSP

Medications for PSP:
* levodopa/carbidopa: might help
* amantadine: might help, even if
* antidepressants: can help with depression and behavioral abnormalities
* sedatives: can help with behavioral abnormalities
* bladder medications: useful
* constipation medications: useful

Constipation can be a side effect of amantadine and antidepressants.

Treatment of Dysarthria and Dysphagia:
* swallowing evaluation (especially a modified barium swallow study – an xray movie of swallowing) is helpful. This evaluation may recommend: thicken thin liquids; avoid tough, dry food; etc.
* speech therapy rarely helpful but worth a try
* amplifying devices often useful
* hand signs
* if patient can direct gaze downward, these might be useful: pointing boards and electronic typing devices. Stroke and brain injury rehab centers have experience with these boards and devices.

TREATMENT TRIALS

Nypta (medication):
* GSK3 beta inhibitor (prevents phosphorylation of tau protein)
* trial being organized; it will start in March 2010 in the US
* Noscira is manufacturer
* may slow progression and help symptoms

[Robin’s note: As reported a couple of weeks ago by Dr. Bordelon, UCLA is one of the trial sites for the Nypta trial.]

Davunetide (medication):
* trial being planned
* Allon is manufacturer
* administered by nasal spray
* may slow progression and help symptoms

[Robin’s note: UCSF is the lead site for this trial, whenever it gets kicked off.]

DBS (deep brain stimulation) of the PPN (pedunculopontine nucleus) for PSP: (Stefani, et al, Brain 2007)
* electrodes (stiff wire) are passed into the PPN of the brain
* Univ of Toronto is experimenting with this
* preliminary results are favorable but we’ll just have to see
* he thinks this may be unwieldy but since it’s one of the few treatments available, people may give it a try
* this will mainly help the balance problem

[Robin’s note: You can find general info on this CurePSP-funded study here — http://forum.psp.org/viewtopic.php?t=7733]

—————–

QUESTIONS AND ANSWERS (all answers were given by Dr. Golbe)
[Robin’s note: I’ve edited the questions, grouped together similar items, and added headings]

TREATMENTS
Question: Are there any clinical trials going on?

Answer: Besides the trials just mentioned, there are others that have been going on for some time.

One trial going on now of CoQ110 at Lahey Clinic in MA. There are other US sites where this trial is being conducted. Contact the CurePSP office to be referred to the Lahey Clinic researcher.

[Robin’s note: this is the first I heard that a CoQ10 trial is being conducted in other places in the US outside Lahey Clinic. I might’ve misunderstood this.]

The lithium trial is still going on but it has stopped recruiting. Most patients had severe side effects.

Dr. Litvan’s epidemiological study is ongoing. It’s not interventional.

Question: Does CoQ10 help any and what is it used for?

Answer: The German trial of CoQ10 (published in mid-2008) did show a benefit even though the treatment was only 6 weeks. The benefit seen was the amount of energy available in the brain was increased, as noted by a special scan. This needs to be confirmed.

[Robin’s note: You can find the abstract of the German study posted here — http://forum.psp.org/viewtopic.php?t=7334 — or look it up on pubmed.gov using PubMed ID#18464278.]

CoQ10 helps with overall brain energy and metabolism. It doesn’t really help symptoms.

Question: What evidence is there on the use of lithium to slow the progression of PSP and what are the associated risks? Does lithium work in the long term?

Answer: Unfortunately, lithium was not well-tolerated by the PSP population so we don’t know if it slows progression. There were many side effects: dizziness, nausea, etc. Lithium is not a realistic treatment for PSP.

Question: Has anyone looked at diet and micro-nutrients to reduce PSP symptoms? I am thinking of antioxidants.

Answer: Antioxidants have been tried in PSP without success.

Question: Are there any other possible treatments to slow the progression of PSP?

Answer: Nypta and Davunetide will be studied in 2010.

Question: Is there anyone who treats PSP with cord blood stem cells?

Answer: No.

We need to consider the goal of stem cell treatment. In PSP, many areas of the brain are affected (with many types of brain cells) so cell replacement therapy isn’t practical. Another issue is how can you get the replacement cells to form proper connections with other cells?

But maybe stem cells can be drug delivery vehicles: program a stem cell to make a drug. No one has gotten this far yet.

Question: Is there good news on the horizon?

Yes. In the past couple of years, there have been a lot of treatment trials in PSP, sponsored by drug companies and the NIH.

Question: What’s the difference between ubiquinone and ubiquinol?

Answer: I don’t know. Ubiquinone is CoQ10.

Question: [Robin’s note: Sorry but I didn’t hear the question. I think it was about the experimental drug Rember.]

Answer: Experts don’t think this works in Alzheimer’s Disease, and it hasn’t been tested for PSP.

[Robin’s note: If the question was about Rember, note that the manufacturer, TauRX in Singapore, has not been willing to supply this medication to be tested in PSP, despite the efforts of US-based researchers to initiate a trial.]

GENETICS STUDY AND SCREENING
Question: When will we see some concrete results from the PSP genetics study, and what kinds of follow-up studies are anticipated?

Answer: We’ll see the replication study results in December or January. Assuming the findings are confirmed, a paper will be published shortly thereafter.

There will be lots of follow-up studies: animal models utilizing the genes; how proteins are behaving and what they are interacting with; drug treatment screening. A “whole new world of research” will be opened up.

Question: What is it so important to confirm four new unsuspected genes?

Answer: This could help with new treatment.

Question: Are genetic screenings available to check for one’s chances of getting PSP?

Answer: No. Even checking for the presence of the H1 haplotype is not that useful.

STAGES AND SURVIVAL
Question: How long does it take for PSP to develop? How long prior to diagnosis has the disease been in place?

Answer: We don’t know for sure. The theory with most neurodegenerative diseases is that they’ve been going on for 5-10 years prior to symptoms appearing.

Question: Why is there such a difference in the survival times of PSP patients?

Answer: Actually, among PSP patients there is less variance in survival times than we see with PD. This may depend on one’s underlying health — how quickly you can fight off pneumonia and how quickly you can heal from injuries. May depend on how many genetic abnormalities you have.

Question: How long will I live after diagnosis?

Answer: No way to know for sure. Seems to be related to the skill and dedication of the caregiver.

Average survival after the first symptom appears is 7-8 years. Some people do better than this.

[Robin’s note: There’s no research evidence to support Dr. Golbe’s assertion that caregivers can influence survival time. It largely depends on what type of PSP you have, your gender, your age at onset, and the interval between disease onset and reaching the first clinical milestone. See, in particular, the “Clinical Outcomes” paper on this topic. At present, it is available for free here — http://brain.oxfordjournals.org/cgi/reprint/131/5/1362]

Question: How can I tell what stage I’m in?

Answer: See the PSP Rating Scale on psp.org. It is a prediction of future survival. There is a margin of error.

[Robin’s note: Dr. Golbe authored the rating scale several years ago. You can find it here — https://www.psp.org/materials/rating_scale.pdf

See this post about an article on interpreting the scale — http://forum.psp.org/viewtopic.php?t=2468]

SYMPTOMS
Question: Is the eye movement problem = downbeat nystagmus?

Answer: [Sorry, I didn’t hear the answer but I’m pretty sure he said “no.” I don’t think there is such a thing as “downbeat nystagmus.” There is downward gaze palsy in PSP and nystagmus.]

Question: Is the eye palsy always downwards?

Answer: No, it can start out upwards. Upward gaze palsy is common among the elderly.

Question: What physiologically causes the stiffness in the neck? Any treatment for this?

Answer: There is no research on this. There’s not even an informal recommendation on this.

Botox can be used for neck stiffness. Botox must be injected cautiously.

Question: Can hunching over occur in PSP?

Answer: Usually there is a very erect posture or a backwards posture. But the majority of PSP patients hunch forward and even sideways (“scoliosis”).

Question: Do you find that a low dose of Prozac can help the spastic speech and dysphagia in PSP?

Answer: I haven’t heard of this.

Question: We are using Seroquel for restlessness and Ambien for sleep. Should my loved one be sleeping/resting more? Are there better choices of drugs?

Answer: Sleep problems in PSP can worsen. Talk to your MD about medications.

PSP VS. CBD
Question: What’s the key difference between PSP and CBD?

Answer: PSP – mostly a disorder of balance (worst problem); symmetric

CBD – balance is not that big of a problem; mostly a problem of the use of limbs; very asymmetric (one side affected much worse than the other side; eventually both sides are affected); apraxia (limb loses the ability to perform a task that has been practiced in the past, such as saluting); issue with perceiving spatial concepts (eg, tracing a number on the palm)

PROTEINS
Question: What is the relationship between alpha-synuclein and tau, and the effect on them by hsp70?

Answer: Alpha-synuclein is associated with Parkinson’s Disease. AS is to PD as tau is to PSP. Complicated: it was recently discovered that in PD there can be a problem with tau. And the H1 haplotype is more common in PD than in normal controls.

hsp70 (heat shock protein 70) is a chaperone protein. They regulate the activity of other proteins. hsp70 help blobs of protein from forming. He can’t speak to the relevance of hsp70 as a treatment in PSP.

[Robin’s note: You can read about the University of South Florida study in mice here — http://forum.psp.org/viewtopic.php?t=8178]

RESEARCH
Question: My husband has been diagnosed with MSA. But PSP now sounds like a possibility. Should we spend more money/effort to study neurodegenerative disorders in general or does specificity help?

Answer: Lots of research is applicable to all neurodegenerative diseases.

OTHER
Question: Is there a connection between PSP and MS (multiple sclerosis)?

Answer: No. MS is an immune disorder. This doesn’t happen in PSP. MS is a disease of the cells that insulate the axons. MS isn’t primarily a disease of brain cell breakdown.

Question: I had a DNA test done and was diagnosed with SCA3. Is it possible that I could also have other forms of a movement disorder? Should I get tested for all disorders?

Answer: SCA3 is a completely different disease.

Question: Is cerebellar ataxia a type of PSP? Is PSP a type of Parkinson’s? Is SCA a type of PSP?

Answer: No (to all three questions).

Cerebellar ataxia is a collection of symptoms related to the cerebellum.