Free Radical Biology & Medicine, Vol. 33, No. 9, pp.

1194 1199, 2002

Copyright 2002 Elsevier Science Inc.
Printed in the USA. All rights reserved
0891-5849/02/$see front matter

PII S0891-5849(02)01021-3

Serial Review: Causes and Consequences of Oxidative Stress in

Alzheimers Disease
Guest Editors: Mark A. Smith and George Perry
AMYLOID- AND SERVE ANTIOXIDANT FUNCTIONS IN THE AGING
AND ALZHEIMER BRAIN
MARK A. SMITH,* GEMMA CASADESUS, JAMES A. JOSEPH,

and

GEORGE PERRY*

*Institute of Pathology, Case Western Reserve University, Cleveland, OH, USA; and USDA-Human Nutrition Research Center on
Aging at Tufts University, Boston, MA, USA
(Received 25 February 2002; Revised 11 July 2002; Accepted 11 July 2002)

AbstractHistorically, amyloid- and (tau), the major components of senile plaques and neurofibrillary tangles,
respectively, have been considered central mediators of the pathogenesis of Alzheimer disease. Therefore, efforts to
understand disease mechanisms have concentrated on understanding either the processes involved in amyloid-
deposition as senile plaques or on the phosphorylation and aggregation of as neurofibrillary tangles. However, in light
of recent evidence, such lesion-centric approaches look to be inappropriate. In fact, rather than initiators of disease
pathogenesis, the lesions occur consequent to oxidative stress and function as a primary line of antioxidant defense.
Given this, it is perhaps not surprising that the increased sensitivity to oxidative stress in the aged brain, even in control
individuals, is invariably marked by the appearance of both amyloid- and tau. Additionally, in Alzheimer disease,
where chronic oxidative stress persists and is superimposed upon an age-related vulnerable environment, one would
predict, and there is, an increased lesion load. The notion that amyloid- and function as protective components brings
into serious question the rationale of current therapeutic efforts targeted toward lesion removal. 2002 Elsevier
Science Inc.
KeywordsAlzheimer disease, Amyloid-, Antioxidant, Free radical, Phosphorylation, Redox-active metals, Tau

INTRODUCTION

factors that led to their formation. Thus, the goal of this

review is to present an alternative hypothesis for the role
of amyloid- and neurofibrillary tangle (NFT) deposition
in this disease.

Amyloid- and the microtubule-associate protein tau ()

are, without a shadow of a doubt, the best-studied proteins relating to the pathogenesis of Alzheimer disease
(AD). While perhaps not surprising since the pathological diagnosis of Alzheimer disease is dependent upon
both amyloid- and depositions [1,2], the amalgamation of diagnostic and mechanistic views relating to the
disease has unfortunately led researchers astray. Amyloid- and are crucial diagnostic indicators; however,
as we discuss below, their mechanistic importance has
far less to do with their consequences than with the

Amyloid-
The overwhelming view currently held concerning
disease pathogenesis is the premise that amyloid-
causes the disease [3]. Champions of the amyloid-
hypothesis argue that diagnostic, clinical, and pathological studies all support a central role for amyloid-. First,
amyloid- is an obligate feature of the disease and correlates, albeit weakly, with disease severity [4]. Second,
amyloid- is often, though not always, found in regions
of the brain that degenerate during the disease and amyloid- is a potent neurotoxic agent in vitro. Third, and
most touted, both in vivo in the disease and in vitro in
transfected cells, amyloid- is increased by all of the
mutated genes (including the source of amyloid-,

1
This article is part of a series of reviews on Causes and Consequences of Oxidative Stress in Alzheimers Disease. The full list of
papers may be found on the homepage of the journal.
Address correspondence to: Mark A. Smith, Ph.D., Institute of
Pathology, Case Western Reserve University, 2085 Adelbert Road,
Cleveland, OH 44106, USA; Tel; (216) 368-3670; Fax: (216) 3688964; E-Mail: mas21@po.cwru.edu.

1194

A and as antioxidants

APP) that are associated with the autosomal dominant

inheritance of AD [5]. However, the aforementioned
points are, at best, circumstantial and may also be used as
evidence that amyloid- is playing a protective role.
First, the correlation of amyloid- with dementia (i.e.,
neuronal dysfunction and loss) appears to be a protective
compensation mounted in response to the underlying
disease process [6]. Indeed, there is insurmountable evidence that oxidative stress is one of, if not the, earliest
pathological alteration in the disease [7,8]. Importantly,
neurons respond to oxidative stress, both in vitro and in
vivo, by increasing amyloid- production [9], and this
increased amyloid- is associated with a consequent
reduction in oxidative stress [7,8]. Proteins, such as
amyloid-, that are induced under oxidative conditions
and act to lessen oxidative damage, are typically thought
of as antioxidants and, in this regard, we recently demonstrated that amyloid- is a bona fide antioxidant that
can act as a potent superoxide dismutase [10].
Viewing amyloid- as a protective response element
provides a valid mechanism for why the brains of almost
everyone over the age of 40, an age, coincidently, where
redox alterations first manifest [8], contain amyloid-
deposits. The alternate view, that everyone at mid-life is
on the verge of developing AD is not only unsound from
a biological perspective but also does a great disservice
to the large percentage of cognitively normal aged individuals whose brains contain amyloid- loads equivalent
to patients with AD [11]. Indeed, although fibrillar or
aggregated forms of amyloid-, like those present in the
senile plaques, cause cytotoxicity in vitro [12], the presence and density of amyloid- in vivo correlates weakly
with the onset and severity of AD [13]. Instead, the
presence of the soluble form of amyloid- in the brain
may be a better predictor of the disease [14]. Specifically, SDS-stable oligomers and not monomers of this
form of amyloid- seem to play an important role, as
shown by augmented presence of these oligomers during
the expression of mutations in APP or presenilin [15],
as well as by their capacity to inhibit neuronal plasticity
parameters (LTP) in vivo when micro-injected into the
brains of rodents [16]. Conversely, amyloid- is not
always present in the brains of cognitively normal elderly. Nevertheless, these differences can be explained in
terms of genetic and environmental variability across
individuals. One possibility is that some people are genetically endowed with more efficient endogenous antioxidant defense systems and thus age better/slower. Alternatively, these people may have supplemented their
diets with foods rich in antioxidants throughout their
lifespan, compensating for age-related declines in these
endogenous systems and thus slowing down oxidative
stress-related declines seen during aging [1719]. If
amyloid- and NFT deposition provides an antioxidant

1195

function, it is likely that these processes will be recruited

during times when oxidative stress is high and the endogenous antioxidant-defenses are compromised. Nevertheless, if these systems remain relatively efficient or are
supported by exogenous antioxidant supplementation,
the presence of amyloid- and NFT may not be necessary, and thus lead to little amyloid- and NFT deposition. Preliminary data from in vitro studies support this
hypothesis. Incubation of primary cortical neurons with
blueberry extract, a fruit rich in antioxidants [1719],
prevents phosphorylation when neurons are presented
with an oxidative stress insult (Casadesus, Smith, and
Joseph, in preparation), analogous to the effects of endogenous antioxidants [20].
Moreover, unbiased stereological counting indicates
that during normal aging there may be little or no cell
loss despite, as pointed out above, the presence of an
increasing number of plaques [21]. This testifies to the
protective function of amyloid-. Importantly, even the
hyper-physiologic levels of amyloid- found in engineered AD transgenic mice [22] only lead to senile
plaque formation in middle-aged mice and are, like their
human counterparts, preceded by oxidative stress [23
25]. Taken together, these findings indicate that amyloid- is not driving the pathogenic process, rather it is a
consequence of the pathogenic oxidative process that
serves an antioxidant function. In normal aging, the
production and deposition of amyloid- successfully
staves off age-related redox imbalances, but in AD where
there is a profound and chronic redox imbalance, the
presence of amyloid-, even at high levels, proves insufficient.
The idea that amyloid- is protective represents a
major paradigm shift but is really not surprising. Neuronal degeneration is associated with a number of responses including the induction of heat shock proteins
such as heme oxygenase-1 [26] and ubiquitin [27,28]
that, like amyloid-, show a relationship with cognitive
decline. Why is it that only amyloid- is considered
pathogenic? The answer, according to the proponents of
the amyloid- hypothesis is that amyloid- is neurotoxic
in vitro and is associated with neuronal loss in vivo.
However, that amyloid- is age- and region-specific is
further consistent with a key role in redox homeostasis.
Cell culture studies showing neurotoxicity may be artifacts of in vitro conditions [29], an aspect further buttressed by the fact that neither isolated senile plaques nor
immobilized amyloid- elicit neurotoxicity in vivo or in
vitro [30 32]. Nonetheless, as a bioactive substance, we
should remain cognizant that antioxidants can also serve
as pro-oxidants, dependent upon the conditions and that,
in certain nonphysiological circumstances, amyloid-
can be made damaging [33,34]. In this regard, and although the capacity of amyloid- to induce oxidative

1196

M. A. SMITH et al.

stress remains controversial [35], recent data illustrate

that the oxidant properties of amyloid- may stem from
its capacity to interact with transition metals and mediate
toxicity via redox-active ions that precipitates lipid peroxidation and cellular oxidative stress [29].
Based on the evidence presented above, the few reports demonstrating, under some circumstances, neuronal loss in some transgenic mice with amyloid- deposits
[36] argue only that amyloid- is a bioactive substance.
Indeed, there is little evidence in the literature showing
behavioral deficits in mice transgenic for only APP
mutations. The most consistent findings of behavioral
deficits have been shown in mice transgenic for more
than one mutation, e.g., APP/PS1 [37,38], and even
then it is superimposed upon an aged environment.
Finally, the notion that genetic linkage mutations
causes increased amyloid- causes disease is simplistic,
pays scant regard for biological and cellular homeostasis,
and is clearly not as direct as often assumed, even in the
case of mutations in APP. While it is true that APP
and presenilin-1 and -2 mutations are deterministic for
the onset of AD and that these mutations produce increases in amyloid- in the brain, it is against logic to
conclude with certainty that there is a casual relationship
between the two. For example, and perhaps not surprising, in light of the antioxidant function of amyloid-,
oxidative stress is among the best inducers of APP
protein expression and consequent amyloid- production
[9]. Therefore, if a mutation causes oxidant stress then
one would also find an increase in amyloid-. Indeed,
together with the in vivo findings showing that increased
amyloid- deposition is associated with reduced oxidative stress [7,8], the finding of increased amyloid- with
the mutants simply highlights that perturbations in the
cellular system lead to a protective response, i.e., increased amyloid- production.
Our arguments supporting amyloid- as a crucial
antioxidant defense mechanism are extremely relevant to
current pharmacological efforts targeted at either removing amyloid- or lessening amyloid- production, and
will likely leave neurons without one of their fundamental compensatory responses to aging and disease.
Tau
As we show for amyloid-, even those aspects of AD
thought most deleterious may actually play an important
role in antioxidant defenses and this aspect applies
equally well to [8]. The accumulation of phosphorylated as NFT in neurons appears to be an analogous
protective antioxidant response, since quantitative analysis of the extent of oxidative damage in AD shows the
oxidative damage is actually reduced in those neurons
with the most cytopathology [8]. For example, recent

data suggests that most neuronal loss in AD occurs prior

to NFT deposition [39,40]. Interestingly, most neuronal
loss during this period occurs when the levels of oxidative stress are highest and subsequent deposition of NFT
decreases these levels [41].
The importance of this protective aspect of is
brought to the fore if it is considered that protection of
critical cellular components from oxidants can be
through the incorporation of damage to others. While
the exhaustion of cellular reductants is usually used as a
measure of antioxidant potential, cellular macromolecules may share a similar function. Consistent with this
view is the physiological modification of and neurofilament proteins by lipid peroxidation products and carbonyls [42,43]. Indeed, oxidative stress and attendant
modification of by products of oxidative stress including HNE [44] as well as other cytotoxic carbonyls [45],
though leading to protein aggregation as NFT, enables
such neurons to survive decades [46]. Intriguingly, although cytoskeletal proteins such as and neurofilaments have a long half-life, the same extent of carbonyl
modification is found throughout the normal aging process as well as along the length of the axon [47]. This
suggests that the oxidative modification of cytoskeletal
proteins is under tight regulation. Both and neurofilament protein appear uniquely adapted to oxidative attack
due to their high content of lysine-serine-proline (KSP)
domains. Exposure of these domains on the protein surface is affected by extensive phosphorylation of serine
residues, resulting in an oxidative sponge of surfacemodifiable lysine residues [47]. Since phosphorylation
plays this pivotal role in redox balance, it is perhaps not
surprising that oxidative stress, through activation of
MAP kinase pathways, leads to phosphorylation [48
51], nor that conditions associated with chronic oxidant
stress, such as AD, are invariably associated with extensive phosphorylation of cytoskeletal elements. Indeed,
other neurological conditions where phosphorylated
and neurofilament protein accumulations occur, also
show evidence of oxidative adducts, e.g., progressive
supranuclear palsy [52] and frontal temporal dementia
[53]. Given this protective role of phosphorylation, it is
not surprising that embryonic neurons that survive treatment with oxidants have more phospho- immunoreactivity relative to those that die [54]. Further, since heme
oxygenase induction and expression are opposing
[20,44], the reduced oxidative damage in neurons with
accumulation may be a part of the antioxidant function of
phosphorylated .
SUMMARY

While amyloid- and are often viewed as harbingers

of disease, the observed decrease in oxidative damage

A and as antioxidants

1197

Fig. 1. As a consequence of age-related oxidative stress, there is an upregulation of phosphorylated and amyloid- that result in NFT
and senile plaques, respectively. Both lesions serve antioxidant functions and limit age-related neuronal dysfunction. However, in AD,
this age-related oxidative stress is compounded by metabolic [43] and metallic [44,45] sources of oxidant stress that, despite greatly
enhancing amyloid- production and phosphorylation, lead to neurodegeneration and consequent dementia.

with amyloid- and accumulation points towards an

alternate, contrary interpretation that they represent important survival responses (Fig. 1) [6,37,5557]. If this
proves to be the case, current efforts targeted at their
elimination will actually exacerbate the disease.

[8]

[9]
Acknowledgements Work in the authors laboratories was funded by
the National Institutes of Health and the Alzheimers Association.

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