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Alzheimer's disease (AD), one of the most common causes of adult dementia, is as yet not well understood at the molecular level. It has been identified as a protein misfolding disease due to the accumulation of abnormally folded amyloid beta protein in the brains of AD patients. Amyloid beta, also written Aβ, is a short peptide that is an abnormal proteolytic byproduct of the transmembrane protein amyloid precursor protein (APP), whose function is unclear but thought to be involved in neuronal development. The presenilins are components of proteolytic complex involved in APP processing and degradation.
Amyloid beta monomers are soluble and contain short regions of beta sheet and polyproline II helix secondary structures in solution, though they are largely alpha helical in membranes; however, at sufficiently high concentration, they undergo a dramatic conformational change to form a beta sheet-rich tertiary structure that aggregates to form amyloid fibrils. These fibrils deposit outside neurons in dense formations known as senile plaques or neuritic plaques, in less dense aggregates as diffuse plaques, and sometimes in the walls of small blood vessels in the brain in a process called amyloid angiopathy or congophilic angiopathy.
AD is also considered a tauopathy due to abnormal aggregation of the tau protein, a microtubule-associated protein expressed in neurons that normally acts to stabilize microtubules in the cell cytoskeleton. Like most microtubule-associated proteins, tau is normally regulated by phosphorylation; however, in AD patients, hyperphosphorylated tau accumulates as paired helical filaments that in turn aggregate into masses inside nerve cell bodies known as neurofibrillary tangles and as dystrophic neurites associated with amyloid plaques. Although little is known about the process of filament assembly, it has recently been shown that a depletion of a prolyl isomerase protein in the parvulin family accelerates the accumulation of abnormal tau. 
Both amyloid plaques and neurofibrillary tangles are clearly visible by microscopy in AD brains. At an anatomical level, AD is characterized by gross diffuse atrophy of the brain and loss of neurons, neuronal processes and synapses in the cerebral cortex and certain subcortical regions. This results in gross atrophy of the affected regions, including degeneration in the temporal lobe and parietal lobe, and parts of the frontal cortex and cingulate gyrus. Levels of the neurotransmitter acetylcholine are reduced. Levels of the neurotransmitters serotonin, norepinephrine, and somatostatin are also often reduced. Glutamate levels are usually elevated.[How to reference and link to summary or text]
Although the gross histological features of AD in the brain are well characterized, three major hypotheses have been advanced regarding the primary cause. The oldest hypothesis suggests that deficiency in cholinergic signaling initiates the progression of the disease. Two alternative misfolding hypotheses instead suggest that either tau protein or amyloid beta initiates the cascade. While researchers have not identified a clear causative pathway originating from any of the three molecular hypotheses to explain the gross anatomical changes observed in advanced AD, variants of the amyloid beta hypothesis of molecular initiation have become dominant among the three possibilities.
The oldest hypothesis is the "cholinergic hypothesis". It states that Alzheimer's begins as a deficiency in the production of acetylcholine, a vital neurotransmitter. Much early therapeutic research was based on this hypothesis, including restoration of the "cholinergic nuclei". The possibility of cell-replacement therapy was investigated on the basis of this hypothesis. All of the first-generation anti-Alzheimer's medications are based on this hypothesis and work to preserve acetylcholine by inhibiting acetylcholinesterases (enzymes that break down acetylcholine). These medications, though sometimes beneficial, have not led to a cure. In all cases, they have served to only treat symptoms of the disease and have neither halted nor reversed it. These results and other research have led to the conclusion that acetylcholine deficiencies may not be directly causal, but are a result of widespread brain tissue damage, damage so widespread that cell-replacement therapies are likely to be impractical. More recently, cholinergic effects have been proposed as a potential causative agent for the formation of plaques and tangles leading to generalized neuroinflammation.
More recent hypotheses center on the effects of the misfolded and aggregated proteins, amyloid beta and tau. The two positions are lightheartedly described as "ba-ptist" and "tau-ist" viewpoints in scientific publications by Alzheimer's disease researchers. "Tau-ists" believe that the tau protein abnormalities initiate the disease cascade, while "ba-ptists" believe that beta amyloid deposits are the causative factor in the disease.
The hypothesis that tau is the primary causative factor has long been grounded in the observation that deposition of amyloid plaques does not correlate well with neuron loss. A mechanism for neurotoxicity has been proposed based on the loss of microtubule-stabilizing tau protein that leads to the degradation of the cytoskeleton. However, consensus has not been reached on whether tau hyperphosphorylation precedes or is caused by the formation of the abnormal helical filament aggregates. Support for the tau hypothesis also derives from the existence of other diseases known as tauopathies in which the same protein is identifiably misfolded. However, a majority of researchers support the alternative hypothesis that amyloid is the primary causative agent.
The amyloid hypothesis is initially compelling because the gene for the amyloid beta precursor APP is located on chromosome 21, and patients with trisomy 21 - better known as Down syndrome - who thus have an extra gene copy almost universally exhibit AD-like disorders by 40 years of age. The traditional formulation of the amyloid hypothesis points to the cytotoxicity of mature aggregated amyloid fibrils, which are believed to be the toxic form of the protein responsible for disrupting the cell's calcium ion homeostasis and thus inducing apoptosis. This hypothesis is supported by the observation that higher levels of a variant of the beta amyloid protein known to form fibrils faster in vitro correlate with earlier onset and greater cognitive impairment in mouse models. and with AD diagnosis in humans. However, mechanisms for the induced calcium influx, or proposals for alternative cytotoxic mechanisms, by mature fibrils are not obvious.
A more recent and broadly supported variation of the amyloid hypothesis identifies the cytotoxic species as an intermediate misfolded form of amyloid beta, neither a soluble monomer nor a mature aggregated polymer but an oligomeric species, possibly toroidal or star-shaped with a central channel that may induce apoptosis by physically piercing the cell membrane. A related alternative suggests that a globular oligomer localized to dendritic processes and axons in neurons is the cytotoxic species.
Relevantly, the cytotoxic-fibril hypothesis presented a clear target for drug development: inhibit the fibrillization process. Much early development work on lead compounds has focused on this inhibition; most are also reported to reduce neurotoxicity, but the toxic-oligomer theory would imply that prevention of oligomeric assembly is the more important process or that a better target lies upstream, for example in the inhibition of APP processing to amyloid beta.
- ↑ Hashimoto M, Rockenstein E, Crews L, Masliah E. (2003). Role of protein aggregation in mitochondrial dysfunction and neurodegeneration in Alzheimer's and Parkinson's diseases. Neuromolecular Med 4(1-2):21-36.
- ↑ Kerr ML, Small DH. (2005). Cytoplasmic domain of the β-amyloid protein precursor of Alzheimer's disease: Function, regulation of proteolysis, and implications for drug development. J Neurosci Res 80(2):151-9.
- ↑ Cai D, Netzer WJ, Zhong M, Lin Y, Du G, Frohman M, Foster DA, Sisodia SS, Xu H, Gorelick FS, Greengard P. (2006). Presenilin-1 uses phospholipase D1 as a negative regulator of beta-amyloid formation. Proc Natl Acad Sci USA 103(6):1941-6.
- ↑ Danielsson J, Andersson A, Jarvet J, Graslund A. (2006). 15N relaxation study of the amyloid beta-peptide: structural propensities and persistence length. Magn Reson Chem Spec No:S114-21.
- ↑ Tomaselli, S., Esposito, V., Vangone, P., van Nuland, N.A., Bonvin, A.M., Guerrini, R., Tancredi, T., Temussi, P.A., Picone, D. (2006). The alpha-to-beta Conformational Transition of Alzheimer's Abeta-(1-42) Peptide in Aqueous Media is Reversible: A Step by Step Conformational Analysis Suggests the Location of beta Conformation Seeding. Chembiochem 7:257-67
- ↑ Ohnishi S, Takano K. (2004). Amyloid fibrils from the viewpoint of protein folding. Cell Mol Life Sci 61(5):511-24.
- ↑ Goedert M, Klug A, Crowther RA. (2006). Tau protein, the paired helical filament and Alzheimer's disease. J Alzheimers Dis 9(3S):195-207.
- ↑ Pastorino L, Shyun A, Lu PJ, Zhou XZ, Balastik M, Finn G, Wulf G, Lim J, Li SH, Li X, Xia W, Nicholson LK, Lu KP. (2006). The prolyl isomerase Pin1 regulates amyloid precursor protein processing and amyloid-beta production. Nature 440(7083):528-34.
- ↑ Lim J, Lu KP. (2005). Pinning down phosphorylated tau and tauopathies. Biochim Biophys Acta 1739(2-3):311-22.
- ↑ Tiraboschi P, Hansen LA, Thal LJ, Corey-Bloom J. (2004). The importance of neuritic plaques and tangles to the development and evolution of AD. Neurology 62(11):1984-9.
- ↑ 11.0 11.1 Wenk GL. (2003). Neuropathologic changes in Alzheimer's disease. J Clin Psychiatry 64 Suppl 9:7-10.
- ↑ Shen ZX. (2004). Brain cholinesterases: II. The molecular and cellular basis of Alzheimer's disease. Med Hypotheses 63(2):308-21.
- ↑ 13.0 13.1 13.2 Mudher A, Lovestone S. (2002). Alzheimer's disease-do tauists and baptists finally shake hands? Trends Neurosci 25(1):22-6.
- ↑ Schmitz C, Rutten BP, Pielen A, Schafer S, Wirths O, Tremp G, Czech C, Blanchard V, Multhaup G, Rezaie P, Korr H, Steinbusch HW, Pradier L, Bayer TA. (2004). Hippocampal neuron loss exceeds amyloid plaque load in a transgenic mouse model of Alzheimer's disease. Am J Pathol 164(4):1495-502.
- ↑ Gray EG, Paula-Barbosa M, Roher A. (1987). Alzheimer's disease: paired helical filaments and cytomembranes. Neuropathol Appl Neurobiol 13(2):91-110.
- ↑ Williams DR. (2006). Tauopathies: classification and clinical update on neurodegenerative diseases associated with microtubule-associated protein tau. Intern Med J 36(10):652-60.
- ↑ Nistor M, Don M, Parekh M, Sarsoza F, Goodus M, Lopez GE, Kawas C, Leverenz J, Doran E, Lott IT, Hill M, Head E. (2006). Alpha- and beta-secretase activity as a function of age and beta-amyloid in Down syndrome and normal brain. Neurobiol Aging Epub.
- ↑ Lott IT, Head E. (2005). Alzheimer disease and Down syndrome: factors in pathogenesis. Neurobiol Aging 26(3):383-9.
- ↑ Yankner BA, Duffy LK, Kirschner DA. (1990) Neurotrophic and neurotoxic effects of amyloid beta protein: reversal by tachykinin neuropeptides Science 250(4978): 279-282.
- ↑ Iijima K, Liu HP, Chiang AS, Hearn SA, Konsolaki M, Zhong Y. (2004). Dissecting the pathological effects of human Abeta40 and Abeta42 in Drosophila: a potential model for Alzheimer's disease. Proc Natl Acad Sci USA 101(17):6623-8.
- ↑ Gregory GC, Halliday GM. (2005). What is the dominant Abeta species in human brain tissue? A review. Neurotox Res 7(1-2):29-41.
- ↑ Blanchard BJ, Hiniker AE, Lu CC, Margolin Y, Yu AS, Ingram VM. (2000). Elimination of Amyloid beta neurotoxicity. J Alzheimers Dis 2(2):137-149.
- ↑ Abramov AY, Canevari L, Duchen MR. (2004). Calcium signals induced by amyloid beta peptide and their consequences in neurons and astrocytes in culture. Biochim Biophys Acta 1742(1-3):81-7.
- ↑ Barghorn S, Nimmrich V, Striebinger A, Krantz C, Keller P, Janson B, Bahr M, Schmidt M, Bitner RS, Harlan J, Barlow E, Ebert U, Hillen H. (2005). Globular amyloid beta-peptide oligomer - a homogenous and stable neuropathological protein in Alzheimer's disease. J Neurochem 95(3):834-47.
- ↑ Kokubo H, Kayed R, Glabe CG, Yamaguchi H. (2005). Soluble Abeta oligomers ultrastructurally localize to cell processes and might be related to synaptic dysfunction in Alzheimer's disease brain. Brain Res 1031(2):222-8.
- ↑ Blanchard BJ, Chen A, Rozeboom LM, Stafford KA, Weigele P, Ingram VM. (2004). Efficient reversal of Alzheimer's disease fibril formation and elimination of neurotoxicity by a small molecule. Proc Natl Acad Sci USA 101(40):14326-14332.
- ↑ Porat Y, Abramowitz A, Gazit E. (2006). Inhibition of amyloid fibril formation by polyphenols: structural similarity and aromatic interactions as a common inhibition mechanism. Chem Biol Drug Des 67(1):27-37.
- ↑ Kanapathipillai M, Lentzen G, Sierks M, Park CB. (2005). Ectoine and hydroxyectoine inhibit aggregation and neurotoxicity of Alzheimer's beta-amyloid. FEBS Lett 579(21):4775-80.
- ↑ Lee KH, Shin BH, Shin KJ, Kim DJ, Yu J. (2005). A hybrid molecule that prohibits amyloid fibrils and alleviates neuronal toxicity induced by beta-amyloid (1-42). Biochem Biophys Res Commun 328(4):816-23.
- ↑ Espeseth AS, Xu M, Huang Q, Coburn CA, Jones KL, Ferrer M, Zuck PD, Strulovici B, Price EA, Wu G, Wolfe AL, Lineberger JE, Sardana M, Tugusheva K, Pietrak BL, Crouthamel MC, Lai MT, Dodson EC, Bazzo R, Shi XP, Simon AJ, Li Y, Hazuda DJ. (2005). Compounds that bind APP and inhibit Abeta processing in vitro suggest a novel approach to Alzheimer disease therapeutics. J Biol Chem 280(18):17792-7.
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