A major global challenge is the increasing prevalence of dementia, especially dementia caused by Alzheimer disease (AD). It is estimated that approximately 100 million people worldwide will have AD dementia in 2050.¹ In the global action plan against dementia, the World Health Organization has specified improved diagnostics as a key area,² since it is important for optimal disease management and treatment. Early, accurate, and biomarker-based diagnosis of AD will likely become even more important when disease-modifying treatments become available.^3,4

Significance: The clinical and pathological variability among patients with Alzheimer’s disease (AD) remains largely unexplained. Evidence is growing that this heterogeneity may be influenced by the heterogeneous molecular architecture of misfolded amyloid-β peptide (Aβ) in the brain. To test this hypothesis, we used unique fluorescent ligands to interrogate the molecular structure of Aβ in amyloid plaques from patients who had died with etiologically distinct subtypes of AD. We found that Aβ-amyloid plaques in the brain cluster as clouds of conformational variants that differ among certain subtypes of AD. The conformational features of AD plaques were partially transmissible to transgenic mice in a seeding paradigm, suggesting a mechanism whereby different molecular strains of Aβ propagate their features within the brain.

We characterized the world’s second case with ascertained extreme resilience to autosomal dominant Alzheimer’s disease (ADAD). Side-by-side comparisons of this male case and the previously reported female case with ADAD homozygote for the APOE3 Christchurch (APOECh) variant allowed us to discern common features. The male remained cognitively intact until 67 years of age despite carrying a PSEN1-E280A mutation. Like the APOECh carrier, he had extremely elevated amyloid plaque burden and limited entorhinal Tau tangle burden. He did not carry the APOECh variant but was heterozygous for a rare variant in RELN (H3447R, termed COLBOS after the Colombia–Boston biomarker research study), a ligand that like apolipoprotein E binds to the VLDLr and APOEr2 receptors. RELN-COLBOS is a gain-of-function variant showing stronger ability to activate its canonical protein target Dab1 and reduce human Tau phosphorylation in a knockin mouse. A genetic variant in a case protected from ADAD suggests a role for RELN signaling in resilience to dementia.

Presenilin (PSEN) pathogenic mutations cause familial Alzheimer’s disease (AD [FAD]) in an autosomal-dominant manner. The extent to which the healthy and diseased alleles influence each other to cause neurodegeneration remains unclear. In this study, we assessed γ-secretase activity in brain samples from 15 nondemented subjects, 22 FAD patients harboring nine different mutations in PSEN1, and 11 sporadic AD (SAD) patients. FAD and control brain samples had similar overall γ-secretase activity levels, and therefore, loss of overall (endopeptidase) γ-secretase function cannot be an essential part of the pathogenic mechanism. In contrast, impaired carboxypeptidase-like activity (γ-secretase dysfunction) is a constant feature in all FAD brains. Significantly, we demonstrate that pharmacological activation of the carboxypeptidase-like γ-secretase activity with γ-secretase modulators alleviates the mutant PSEN pathogenic effects. Most SAD cases display normal endo- and carboxypeptidase-like γ-secretase activities. However and interestingly, a few SAD patient samples display γ-secretase dysfunction, suggesting that γ-secretase may play a role in some SAD cases. In conclusion, our study highlights qualitative shifts in amyloid-β (Aβ) profiles as the common denominator in FAD and supports a model in which the healthy allele contributes with normal Aβ products and the diseased allele generates longer aggregation-prone peptides that act as seeds inducing toxic amyloid conformations.