Age, Vol.
18, 97-119, 1995
FREE RADICAL THEORY OF AGING: ALZHEIMER'S DISEASE PATHOGENESIS
Denham Harman*
University of Nebraska College of Medicine
Department of Medicine
Omaha,, Nebraska 68198-4635
ABSTRACT
Serlife dementia of the Alzheimer's type (SDAT) is
the major cause of dementia. SDAT cases can be
categorized into two groups: 1) late onset, after
abo~t age 60, 90-95 percent of cases; largely non-
fapdlial, i.e., sporadic, 2) early onset, before about
age 60; 5-10 percent of cases, m o s t - - if not all - - are
familial. It is a systemic disorder whose major mani-
festations are in the brain. The brain lesions in both
early and late-onset SDAT are the same as those
seen in smaller numbers in normal older individuals.
It is hypothesized that SDAT is caused by in-
creased free radical reaction levels in brain neurons
that advance in time patterns of neuronal dysfunc-
tion and cell loss. Measures to this end include:
1) mutations in mitochondrial (mt) DNA and/or
nuclear (nuc) DNA in a somatic cell early in develop-
ment that adversely effect mitochondrial function,
2) mutations in maternal mtDNA and/or nucDNA that
impair mitochondria in offspring, 3) mutations in the
amyloid precursor protein (APP), and 4) increased
formation of both normal APP and superoxide
dismutase (SOD).
The incidence of SDAT may be decreased by
efforts to minimize free radical reactions involved in
initiation. The clinical decline of SDAT patients may
be slowed by measures which lower the level of
more-or-less random deleterious free radical reac-
tions.
INTRODUCTION
Senile dementia of the Alzheimer's type (SDAT) is the
major cause of dementia (1). SDAT cases can be cat-
egorized into two groups on the basis of age of onset:
1) Late onset, after age 60, 90-95 percent of cases (2),
largely non-familial, i. e., sporadic (2); there is a slight
increased incidence in near relatives (1,3,4).
2) Early onset, before about age 60, 5-10 percent of
cases (2), almost all familial; most are associated with
chromosome 14 (2,5) (gene product unknown), some
with chromosome 1 (6) (gene product unknown), while a
few have mutations of the gene for the amyloid precursor
protein on chromosome 21 (6,7).
*To whom all correspondence Should be addressed:
Denham Harman. M.D.
University of Nebraska College of Medicine
600 South 42nd Street
Box 984635
Omaha. NE 68198-4635
97
The pathologic lesions in both early and late onset
SDAT are the same (1) and have the same distribution
pattern in the brain. The major risk factor for SDAT is
age; the prevalence increases exponentially with age
(8,9). The age-specific death rate of individuals with
SDAT is 2-4 times that of individuals in the general
population (8).
Atypical clinical presentations occur in about 10 per-
cent of patients with the disorder (1). These include
progressive aphasia, visual agnosia, personality distur-
bance and pure memory loss; such focal features may
predominate for up to four years before the more typical
generalized deficit is apparent (1).
SDAT is a widespread disorderwhose major manifes-
tations are in the brain (8,10). These spread through the
brain producing a constantly changing pattern (11) of
cognitive (1,12,13) and noncognitive symptoms (11).
Systemic manifestations include:
1) calcium content of cultured skin fibroblasts from
patients with Alzheimer's disease is increased while
mitochondrial oxidation of glucose and glutamine are
depressed (10,14)
2) there is a decrease in the major membrane phos-
pholipids, phosphatidylcholine and phosphatidyletha-
nolamine, in brain (15) as well as in erythrocytes (16)
3) cytochrome oxidase was depressed in mitochon-
dria from platelets of five out of 6 patients with a diagno-
sis of Alzheimer's disease (! 7).
PATHOLOGY
SDAT is characterized (1,8,18-23) by: (1) intraneu tonal
fibrillary tangles, (2) plaques - - diffuse, neuritic and
burned-out, and (3) cell loss. These same changes may
be present in the brains of elderly non-demented indi-
viduals (1,24,25). The neuritic plaques and neurofibril-
lary tangles are distributed in the brain in a pattern
similar to that of neuronal cell loss (1).
Description
1. Neurofibrillary tangles
These are (26) are insoluble deposits in neu tonal
, cell bodies, apical dendrites, and distal dendrites
(neuropil threads): after cell death they may accu-
mulate in the neuropil as "ghost" tangles. The
aPl~.~arance of neurofibrillary tangles and neuropil
thr~a.ds generally follows a characteristic, sequen-
tial pattern of distribution in the brain areas associ-
ated with SDAT; the degree of involvement of the
affected areas increases progressively with time.
 The pattern, usually starting in the transentorhinal
pre-~ projection neurons, permits the differentiation
of SDAT into six stages (27). The tangles are
bundles of submicroscopic filamentous structures
(each of which is about 10 nm in diameter) that are
wound around each other in a helical fashion-- the
so-called paired helical filament (PHF); the fila-
ments are composed almost entirely of the
microtubule-associated protein tau in an abnor-
mally phosphorylat~d state (26). Cells witfi tangles
ultimately die (28).
Neurofibrillary t~rrgles (23,28,29), as well as the
loss of synapses .(30,31), are associated with the
dementia of Alzheimer's disease; memory loss
mainly with tangle~ cognitive abilities largely with
synaptic loss (327:
Fibrillarytangies resembling neurofibrillarytangles
have been found in oligodendrocytes in Alzheimer's
disease brains (33).
2. Plaques
Th ere are three types (23):
a) diffuse - - mostly Congo red negative 13A pep-
tides, i.e., preamyloid, without abnormal neurites.
b) neuritic--presence of both dystrophic neurites
and Congo red positive 13A peptides, i. e., amy-
Ioid.
c) burned-out--dense amyloid with reactive astro-
cytes, without dystrophic neurites.
The neuritic plaque and the remnant derived from
it, the burned-out plaque, are associated with
Alzheimer's disease.
A neuritic plaque consists of: 1) degenerative
neuronal processes, 2) amyloid, and 3) a halo of
reactive non-neuronal cells (22). Degenerating neu-
ronal processes constitute the primary lesion while
the reactive cells and amyloid are secondary phe-
nomena (22). Neuritic plaques are associated with
neuronal cell loss (34,35). The plaque is a spheri-
cally shaped cluster of degenerating dendritic and
axonal nerve endings mdystrophic neurites, from a
number of neurotransmitter systems (8) - - sur-
rounded by proliferating astrocytes and by microglial
cells (36,37). Most of the dystrophic neurites a r e
unmyelinated presynaptic terminals distended by
numerous lamellar lysosomes, abnormal mitochon-
dria, and PHS's identical to those making up the
neu rofibrillary tangle in the neuronal perikarya (20);
these changes seem similar to those seen in vita-
min E deficiency (38). The dystrophic neurites usu-
ally surround a core of amyloid protein, i.e., Congo
red positive fibrillary I3A peptides; most of the ~A
peptides in the brain are present in diffuse plaques
in a "preamyloid" form (27,28). Dystrophic neurites
are also found free in the neuropil.
High levels of enzymatically competent lysoso-
real proteases are present in the neuritic plaques,
localized primarily to lysosomal dense bodies and
lipofuscin granules (39,40). Other proteins present
in the plaques include: 1) serum amyloid P compo-
98
nent (SAP) (41), complement C3 component (42),
basic fibroblast growth factor (43), and protein
kinase C (44).
The appearance of degenerating mitochondria in
axonal terminals is apparently the first indication of
plaque formation (22); the mitochondria appear to
be undergoing a change similar to that caused bv a
reduced ATP/ADP ratio (20).
3. Cell loss
Neuronal loss is greatest with the large pyramidal
ceils m discussed below.
Location
Major areas of involvement include those listed in
Table 1.The hippocampal formation and parahippo-
campal gyrus are among the brain areas most
consistently and heavily implicated in SDAT (45);
Table 1. SDAT: major areas of involvement
1. Hippocampalformationand entorhinalregionof the
allocortex.
2. Isocortical association areas of the neocortex.
3. Locusceruleus.
4. Nucleusbasalisof Meynert.
5. The raphenucleus.
in some cases of SDAT the hippocampat formation
may be the only area involved (46). Cells in the
superficial layers of the entorhinal cortex, located in
the parahippocampal gyrus, that project to the
hippocampus are the first to show fibrillary tangles
and to die (45). Progression of such changes
decreases cortical input to the hippocampus through
the entorhinal cortex while'similar degradative
changes in the subiculum and CAI zones of the
hippocampal formation limit output of intrinsic hip-
pocampal circuits. Collectively these changes re-
sult in memory impairment (45,47), a major mani-
festation of SDAT.
Formation
1. Neurofibn'llary Tangles
a) Lipofuscin
Apparently the initial stages of neurofibrillary
tangle development are associated with lipofuscin
(age pigment) deposits (28,48) and/or with the
smooth endoplasmic reticulum (49). Lipofuscin
is prominent in neurons. These deposits accu-
mulate with age in the various areas of the
human central nervous system in parallel with
the activities of oxidative enzymes (50). The rate
of lipofuscin formation can be increased in the rat
(51,52) by raising the level of free radical reac-
tions, e.g., byvitamin E deficiency, orby increas-
ing the degree of unsaturation of the lipid mem-
branes (51,52).
The fatty acid composition of the mammalian
.,brain is essentially independent of the fatty acid
composition of dietary lipids except for the con-
tent of 22:6~3 and its precursors (53,54). Both
linolenic acid (18:3o33) and docosahexanoic acid
(22:6co3) are avidly taken up from the diet by rats
Pathogenesis of Alzheimer'~Disease
and reflected in increasing brain levels of 22:6ex3
(53,55-57) largely at the expense of 22:5(o6,
individual differences being determined by diet
and genetic influences. Brain 22:60)3 is tena-
ciously retained (53); this highly unsaturated
fatty acid is concentrated in the phospholipids of
neurons, both in the perikaryon (58) and the
synaptic area (58,59).
There is a sex difference in the rate of incor0o-
ration of dietary 22:60)3 and its precursors into
brain lipids in rats, b.P,~g higher in females (55).
If this sex difference ~salso present in humans it
may be a factor in the higher incidence of senile
dementia and eadier onset of brain atrophy in
women (60)
Li pofuscin is a product ot the Cellular recycling
system (61). This is an important system in
neurons judging from their large complement of
lysosomes (8,62,63). Cellular components that
are no longer needed or have been altered, are
"marked" (64) and then broken down forreuse by
the cell. Oxidative alterations to some mol-
ecules serve to "mark" them for disposal. Oxida-
tion is a prominent means of "marking', at least
that of metal-catalyzed oxidation of proteins (65-
68). Protein altered by metal-catalyzed oxida-
tion are highly susceptible to proteolysis (68-71).
Protein "marking" can occur at a high rate judg-
ing from : 1) studies on protein turnover (72)
e.g., in the liver the rate may vary from 0.3 to 4.5
percent per hour (72), and 2) the rapid accumu-
lation of lipofuscin-like material in the presence
of the protease inhibitor leupeptin (73-75). The
steady state percentage of cellular proteins
marked by oxidative change, determined by the
rates of protein synthesis and of oxidation and
proteolysis, increases exponentially with age
(67,68) so that 40-50 percent of the protein in an
older individual may be damaged (68,71).
The "cellular recycling system" becomes less
effective with age (61) because of the increasing
rate of initiation of free radical reactions with
advancing age (68,76-79) and the associated
decrease in protease activity (68) so that even-
tually there may be time for "marked" compo-
nents to be converted to forms that are resistant
to cellular breakdown. These altered compo-
nents gradually accumulate, forming lipoluscin.
The cell content of lipofuscin is essentfarly the
same in normal and SDAT brains (48); that in the
small fraction of cells forming tangles is higher
(48).
Oxidative stress (higher than normal levels of
more-or-less random free radical reaclions) is
higher in Alzheimer's patients as demonstrated
by:
1) lower than normal serum levels of vifamin A
and E and of ~3-carotene (80) in patients who
were otherwise well nourished
99
2) higher expression (81,82) of heme oxy-
genase-1 (83) in the brain
3) increased 02 consumption - glucose utiliza-
tion by cerebral cortex biopsy specimens (84)
is increased as well as the uptake of 2-
deoxyglucose by B cells (85)
4) increased activity of glucose-6-phosphate de-
hydrogenase (G6PD) in the brain (86)
5) the widespread activation of calcium-acti-
vated neutral proteinase (calpain) in the brain
(87) --this may in turn trigger events leading
to formation of free radicals (88)
The increased activity of G6PD in the brains of
patients with SDAT is probably responsible for
maintaining gtutathione concentration at a nor-
mal level (89) as well as that of the free radical
reactions involved in lipofuscin formation.
The increased lipofuscin in the dying tangle
cells - - a small fraction of the total cells at any
given time - - probably results from marked
progressive increases in superoxide radical and
H202 formation, and falling ATP production, by
the senescent mitochondria which overwhelms
the cellular defenses against free radical reac-
tion damage (77).
b) Paired helical filament formation
PHF's are composed almost entirely of the
microtubule-associated protein tau (26). Six
isoforms (352-441 amino acids) are found in the
adult human brain; these are produced from a
single gene through alterna~'ve mRNA splicing
(90,91). The isoforms differ from each other in
adult brain by the presence of three Or four
tandem repeats of 31 or32 amino acids in the C-
terminal region; some isoforms have inserts
located near the N terminus (91). The repeats
constitute microtubule-binding domains (92).
Tau is a phosphoprotein with one or two
cysteine residues, depending on the isoform,
located in the tandem repeat region (93). In
normal adult brain tau is phosphorylated at two
or three sites on all six isoforms (94); phospho-
rylation occurs mainly at serine-proline or threo-
nine-proline motifs (95). A number of kinases
phosphorylate tau (96-98), but only the phos-
phorylation by calcium calmodulin dependent
protein kinase (CaMK) (96) shows the pro-
nounced shift in electrophoretic mobility charac-
teristic for tau from Alzheimer neurofibrillary
tangles; apparently only a single phosphoryla-
tion site is responsible for this shift- located in the
C-terminal tail of the protein outside the region of
internal repeats (96).
Phosphorylation of tau in the normal adult
brain occurs at only a few of the 17 serine/
threonine-proline sites, while the tau of PHF's is
phosphorylated at a large number of them (26,99)
- - i.e., abnormally phosphorylated. Alzheimer-
like phosphorylation of tau reduces binding and
 leads to destabilization of microtubules (95).
Such phosphorylation is not required for PHF
formation as tau (100), and constructs corre-
sponding to the repeat region of tau (93), un-
dergo self-assembly, forming Alzheimer-like
PHFs; linked antiparallel dimers of constructs
beh-ave similarly (93).
PHF's also contain apolipoprotein E - - prob-
ably 0nly apo E2 and apoE3 (101), and products
resulting from the glycation oftau (102). Ubiquitin
i~corijugated with amino-terminally processed
9 tau in the PHF's (103), most likely after free
radical damage to tau (104). Six percent of the
proline residues in the PHF's become oxidized
l"5"hydroxyproline (105).
" The progressive oxidative stress associated
with age (68,76-79), like that due to menadione
(106), should eventually cause sustained eleva-
tion of calcium concentrations --one of the means
of inducing apoptosis (107) - - i n the intracellular
compartments; this leads to disruption of the
cytoskeleton and activation of calcium-dependent
catabolic enzymes including phospholipases, ki-
nases, proteases and endonucleases (108-110).
In the case of neurons the foregoing may be
exacerbated by overstimulation of receptors for
excitatory amino acids (111-114).
Activation of kinases such as CaMK may be
expected to progressively phosphorylate tau
and thereby decrease the strength of its binding
with microtubules. The latter permits phospho ry-
lated tau to self-assemble and form PHF's, while
concomitantly the destabilized microtubules
breakdown. In accord, elevation of the intracel-
lular Ca 2§ levels in cultured human cortical neu-
rons (115) causes ultrastructural and antigenic
changes in the cytoskeleton similar to those
seen in neurofibrillary tangles.
In the light of the above it is likely that PHF's
are formed by the events listed in Table 2, taking
place more or less simultaneously as oxidative
stress rises in the neuron.
Table 2. PHF formation
It is likely that the followingeventstake place more or less
simultaneouslyas oxidativestress rises in the n e u r o n :
1. Tau molecules,includingglycatedforms, are oxidizedto
form dimersjoinedby a disulfide link; sometau molecules
also formdisulfidedimerswithapolipoproteinE2or apo E3
that may be present.
2. Oxidativeshorteningof the N-terminalportionof tau which
is thenmarkedby ubiquitinfor proteolyses--ineffectivein
this case: this processmay also occurafterincorporation
into the PHF.
3. Prolinebecomeshydroxylated:6 percentof proline in the
PHF's is hydroxyproline.
4. Tau becomes"abnormallyphosphorylated".
5. Tau molecules,modifiedby the above processesto vari-
able degrees,.self-assembleto form PHF,s.
6. Formation of further disulfide cross-links and oxidative-
polymerization reactions similar to those involved in
lipofuscin formation increasethe stability of the PHFcore.
100
2. Neuritic Plaque Formation
Destruction of the axonal terminal areas of the dying
neurons can be attributed to increases in calcium-
dependent catabolic enzymes, enhanced forma-
tion of the superoxide radical and H20~, lowered
formation of ATP by the impaired mitochondria, and
decreased delivery of free radical reaction inhibitors
from the perikaryon.
Neuritic plaques do not form around the perikaryon
of the dying neuron; this may be related to the
metabolic differences (116) between synaptic and
perikaryonal areas; e.g., 02 consumption by synap-
tic mitochondria is higher than for those of the
perikaryon.
a) Dystrophic~neurites
The dystrophic neufites of the neuritic plaques may
be formed by the joint action of free radicals and
activated catabolic enzymes, both from the synap-
tic areas of the dying neurons, on adjacent neurites.
In addition, oxidative-induced compaction of aggre-
gated I3A peptides in the area could also damage
the neurites by increasing: a) intracellular H202
levels, and b) nitric oxide (NO) formation by acti-
vated microglial cells - - discussed below. The
foregoing may contribute to formation of the exten-
sive network of PHF tau-rich dystrophic neurites
present in preamyloid plaques (117).
b) Amyloid
The amyloid present in the a~rnyloid cores are de-
rived from soluble 13Apeptides produced during the
course of normal metabolism (118-120). This is
accomplished by endocytosis of APP followed by
lysosomal processing and subsequent secretion o f
a number of breakdown products, including
amyloidogen!c and potentially amyloidogenic forms
(120,121) in the same manner as for other proteins
(122-124). In addition, as cellular metabolism falls
the delivery of APP to the axon terminal membranes
may be impaired (125) so that progressively more
APP is sequestered in lysosomes; this could even-
tually contribute to the core amyloid upon breakup
of the terminals.
The rate of accumulation ofl3-amyloid in the brain
may increase with age; 13-amyloid accumulates in
the aging brain of a number of mammalian species
with different life-span potentials (126). However,
the total of amyloid, soluble J3A-peptides, and
preamyloid (see below) in the brain does not in-
crease indefinitely with age; it reflects the balance
between formation and degradation (127).
In vitro studies demonstrate that conversion of
soluble I3A peptides to insoluble amyloid is rate
limited by nucleation, akin to crystallization
(128,129). During the lag phase the soluble 13A
peptides associate to form dimers, trimers, and
higher aggregates (n-mers). A n-mer may then
serves as the nucleus to "seed" formation of fibrils.
The lag time, longer with t3A(1-40) then with 13A(1-
42) or pA(1-43) (128-130). is also determined (131-
134) by peptide concentration and the nature of the
local environment, including the pH. The lag time
with 13A(1-40) is increased by apolipoprotein E
(129); more so with apoE3, particularly the apoE3
dimer, than with apoE4 owing to the greater sup-
pFession of nucleation by apoE3.
Substances that serve to "seed" conversion of~A
peptides to fibrils include: 1) zinc (135,136), alumi-
num (136), and iron (136), 2) heparan sulfate
~roteoglycan (HSP) (137), 3) by products of the
reaction of glucose with 13-amytoJd (138), and ~ -
antichymotrypsin (139). In the latter study both
apoE3 and apoE4 also promoted fibril formation
from 13A(1-42), the effect being greater with apoE4
than with apoE3. The foregoing apoE effect is the
reverse of that noted above (129); it may have been
due to the more rapid formation of a fibril "seed" by
the higher rate of the oxygen-mediated reaction
between thel3A peptide and apoE4 than with apoE3
(140,141).
13A peptides are produced by many cell types
(118,139). The differences in regional concentra-
tions of ~A peptides and the derived fibrils is deter-
mined, at least in part, by the local availability of
"seeds", aggregation inhibitors (139), proteases,
and of the serum amyloid P component (SAP) (41)
that serves to inhibit proteolysis of 13A peptides.
In vivo,13A peptides are present as such in low
steady state concentrations and in two fibrillary
forms: 1) most are in a form not recognized by the
usual Congo red and thioflavin methods, i.e.,
preamyloid (142) - - also named diffuse or amor-
phous plaques, 21 the minor fraction is amyloid, i.e.,
recognized by Congo red.
The major 13A peptide present in both fibrillary
forms in individuals with sporadic (143-146) and
familial [146) SDAT, and Down's syndrome (147) is
13A(1-42) along with some 13A(1-43); most likely
also in dementia pugilistica - - see below. The
absence of 13A(1-40) in fibrillary form suggests that
it had been proteolyzed while the more rapidly
aggregating peptides converted to resistant forms.
Conversion of the fibril form of the 13A peptides
present in preamyloid to that in amyloid may be
primarily due to oxidative-polymerization free radi-
cal reactions (148); conversion probably normally
increases slowly and progressively with advancing
age owing to the rising level of free radical reactions
(i. e., oxidative stress) (76,77). These are initiated
in some cases by catalysts such as heme (81) and
in others by dying neurons, and serve to covert the
fibrils to forms recognized by amyloid stains. The
oxidative reactions may also involve other com-
pounds present, e.g., apolipoprotein E (140); the
co-oxidation with apoE4 is faster than with apoE3
(141) - - possibly because apoE4 has two arginine
residues while apoE3 has one arginine and one
101
cysteine (although both arginine and cysteine readily
undergo metal-catalyzed oxidation [67] the rate of
the co-oxidation is apparently greater in the pres-
ence of two arginine residues). Other compounds
that may be involved in co-oxidation with 13A pep-
tides/amyloid fibrils include SAP (41), HSP (137),
132-macroglobulin (149). and complement compo-
nents (150).
The claim that !3A peptides spontaneously frag-
ment in vivo (151,152) to form free radicals is
chemically very unlikely. Most likely, the free radical
signals seen in these two electron paramagnetic
resonance (EPR) studies - - only in the presence of
02- - are probably due to oxidative reactions initi-
ated by metals; e.g., iron and copper, present on
the surface!of the EPR cell.
The major" steps in neuritic plaque formation are
summarized in Table 3.
Table 3. Neuriticplaqueformation
Definition:
Clusterof degeneratingdendriticand axonalnerveendings(dystro-
phic neurites)usuallysurroundinga core of amyloidprotein
Formation:
1. Distructionof synapticareasis secondaryto increasingoxidative
stress.The lattercauses:
a) increasesin catabolicenzymes
b) Increased free radical reaction damage to cellular
compomemts, including mitochondria - resultingin further
increasesin superoxideradicaland hydrogenperoxidepro-
duction and decreasesin ATP formation
c) Decreaseddeliveryof free radicalreactioninhibitorsfromthe
perikaryon
2. Freera.dicalsand catabolicenzymesfromdyingterminalsacton
adjacentneuritesformingthe dystrophicneurites
3. Amyloidcore
a) Soluble ~A peptides, predominately 13A(1-40)with some
13A(t-42) alongwith a smalleramountof ~A(143),form by
endocytosisof APP followedby lysoeomalprocessingand
subsequentsecretion
b) Aggregationof ~A(1-42), probablealso some ~A(1-43) to
form preamyloidfibrils-- thesedo not stainwith Congored.
13A(1-40) is lost by proteolysis. The aggregationrate is
determined by:
1) Structure
2) Concentration
3) Localenvimoment,e.g.,pH,Zn concentration
4) Oxidativereactions-- major factor determing rate and
extentof aggregation;probablyalso involvesothercom-
pounds suchas apoliproteinE. Conversionof preamyloid
(Congorednegative)to amyloid(Congoredpositive)may
be due to oxidative-polymerizationreactions
3. Cell loss
a) Neurons
Neuronal loss is greatest with the large pyramidal
neurons (153). Whether or not these cells are
always replaced by a neurofibrillary tangle and a
neuritic plaque in not known. The absence of an
inflammatory response in the brain suggests that
cell death is by apoptosis (107,154-157). A study of
cell death in Alzheimer's disease showed that the
number of neurons with DNA fragmentation was
al~0.ut 50 times greater in Alzheimer's disease pa-
tients than in controls (158). Although these changes
were believed to be indicative of necrosis (154)
rather than apoptosis, they could represent the
 early stages of apoptosis (159). About 25 percent of
the degenerating cells were located within areas of
13A peptide deposition, the largest fraction of these
were located in senile plaque areas (158).
a. 1) Amyloid
Aggregates of I3A peptides can be toxic in
neuronal cultures (160-163). Apparently when
in the form of fibrils recognized by Congo red,
the concentration of the l]A peptides in the
antiparallel l]-sheet conformation on the neu-
ronal membrane is high enough to perturb it in
such a manner that an NADPH-linked oxidase
is activated (163). The latter increases cellular
H202 (164) which in turn results in apoptotic
death (165); at least one study reports that [3A
peptide causes death by necrosis (166). In
accord with the foregoing, vitamin E protects
neuronal cells in culture from &A peptide toxic-
ity (167).
In agreement with the observation that aggre-
gated 13A peptide fibrils in a form stained by
Congo red is required for cell toxicity, the diffuse
deposits of Congo red-negative amyloid fibrils
(preamyloid) seen in SDAT (142,168-171 ) and
Downs syndrome (172), contain few or no de-
generating neurites or reactive glial cells.
a.2) Nitric oxide
The deaths of some neurons may be mediated
by nitric oxide formed by activated microglial
cells (173-175), present forthe most partamund
the periphery of neuritic plaques. 13Apeptides
in the Congo red positive fibrillary form activate
m croglial cells in the presence of interferon-I]
(175) - - apparently derived from astrocytes
(176,177). The activated microglial cells in-
crease production of tumor necrosis factor-13
which in turn results in the formation of nitric
oxide (175). This mechanism of cell death may
contribute to the higher death rate of cells
located in areas of amyloid deposits, particu-
larly in neuritic plaques (158).
b) Glial cells
The rate of glial cell deaths is aBOUt Z5 times
higher in Alzheimer's disease than in controls
(158); it is higher in oligodendrocytes than
among microglial cells (158).
PATHOGENESIS
There is no agreement on the pathogenesis of SDAT.
Observations that proposed mechanisms must account
for include those listed in Table 4.
Substances that have been suggested to play a
significant role in pathogenesis include: 1) amyloid, 2)
aluminum, and 3) the etiologic agent of the spongif(~rm
encephalopathies (SE). These suggestions are dis-
cussed below along with the possibility that Alzheimer's
disease may be the result of faster aging of the cells
102
involved in the disorder. Dementia pugilistica, a related
disorder, and Parkinson's disease will be considered
briefly.
Table 4. Observationsthat proposed mechanisms for SDAT must
account for include:
1) It is systemic.
2) Majorriskfactor is age.
3) Lesionsare identical to thoseseen in normal older individuals.
Amyloid
The conspicuous presence of amyloid in neuritic plaqu~,
has prompted a number of hypotheses to account for th6
role of amyloi din pathogenesis (178-183). Studies in
support of this possibility include:
1) Mutations in APP (7) have been found in some-
families with familial Alzheimer's disease
2) Focal deposition of a peptide corresponding to the
first 40 amino acids of 13-amyloid in adult rat
cerebral cortex causes neuronal and neuritic de-
generation (184); this was not confirmed in mon-
keys (185)
3) Aggregates ofl3A peptides can be toxic in neuronal
cultures (160-163) m see discussion above
The above data seems to strongly suggest that amyloid
plays a significant role in the pathogenesis of S'DAT.
However, this may not be the case. The presence of
amyloid does not necessarily precede the appearance of
neurofibrillary tangles (19,27,186,187), especially in the
hippocampus, nor can it account for the systemic nature
of the disorder. Although amyloid may play a major role in
late onset, familial SDAT, and in familial SDAT associated
with mutations in APP, it is primarily a risk factor for the
large majority of SDAT cases - - see below.
Aluminum
Aluminum is an abundant element with numerous di-
verse biological effects (188,189) but no known role.
Interest in the chance that aluminum might have a role
in SDAT was raised in 1965 when neurofibrillary tangles
were observed after aluminum sulphate was injected
intracerebrally in rabbits (190). Subsequent studies with
aluminum salts (191) showed that the fibrils.were single,
not paired as in SDAT. Similar neurofibrillary changes
were seen in neuroblastoma cells exposed to aluminum
in culture (192).
Two cases of dialysis encephal0Pathy (193-195) -
progressive dementia associated with myoclonus,
dysarthria and ataxia - - have been reported in which
neurofibrillary changes, similar to those in animals with
aluminum toxicity, were found in cortical neurons (195).
DipJysis dementia is an uncommon complication of long-
term hemodialysis, associated with elevated levels of
aluminum in the tap water used for dialysis and with high
levels..,of aluminum in the brain; apparently aluminum
gains ~ccess to the brain, at least in part, by way of
transferrin (196) and is then stored in the cytoplasm
(197,198)-- largely in lysosomes (197,198). A recent
laser microprobe analysis of the aluminum content of
neurons in the hippocampus of SDAT patients and
controls showed no significant differences (199); a sec-
ond recent study was in accord (200).
In view of the above, aluminum is probably not directly
involved in the pathogenesis of SDAT. Yet, the inci-
dence of SDAT is positively associated with the level of
aluminum in the drinking water (201) M t h e data may be
flawed (202,203); aluminum may be a risk factor for
SDAT - - discussed below.
Spongiform Encepha/opathies (SE)
These diseases are transmissible neurodegenerative
disorders characterized by the triad --spongiform
encephalopathy, neuronal loss, and gliosis (204). In
humans they include Kuru of the Forte region of New
Guinea, Creutzfeldt-Jakob disease, the Gerstmann-
Strausster-Scheinker syndrome, and their related atypi-
cal forms (204,205); the animal counterparts include the
scrapie of sheep and goats and bovine spongiform
encephalopathy.
As many as one third of individuals with SDAT may be
clinically indistinguishable from those with SE (204).
Th is once raised the possibility that SDAT and SE might
share a common pathogenesis (206). These are now
known to be separate disorders. SE, i.e., the prion
diseases, are caused by the prion protein PrP 27-30
(205,207,208). Molecular biology offers the surest method
of diagnosis (204).
Faster Aging of Neurons Associated with SDA T
The major purpose of this paper is to present data
supporting the hypothesis that Alzheimer's disease is
caused by increased free radical reactions levels in brain
neurons that bring forward in time the sequential pat-
terns of neuronal dysfunction and cell loss associated
with the disorder. Measures to this end that could
account for the Alzheimer's disease observations listed
in Table 4, include those listed in Table 5.
Table 5. Measuresthat can advancein time neuronaldysfucntionand
death, and also accountfor the knowledgeaboutAlzheimer'sdisease.
include:
1) Mutation(s) in mtDNA and/or nucDNA in a somatic cell eany in
developmentthat adverselyaffect mitochondrialfunction
2) Mutation(s)in maternalmtDNAand/ornucDNAthatimpairmitochon-
ddal function in offspnng
.3) Mutationsin APP
4) Increasesin the cellular levelsof both normal APP and superoxide
dismutase
The data supporting the involvement of free radical
reactions in AIzheimer's disease will be followed by a
brief discussion of this disorder in patients with Down's
syndrome.
1. Alzheimer's disease
a) Late onset, sporadic SDAT
a.1) Aging and mitochondria
Neurons involved in the lesions associated with S[~,T
are apparently aging at a faster than normal rate as the
same lesions are seen at later ages in normal individuals
103
(1,24,25). Aging is the accumulation of changes that
increase the risk of death (76,209,210). There is a
growing consensus that these deleterious changes are
produced by free radical reactions (76,209,210), initi-
ated largely by the mitochondria in the course of normai
metabolism at a rate which progressively increases with
age (76.211-218), while the life span of an individual is
determined by the rate of such damage to the mitochon-
dria (76, 211-214,218).
Although most of the mitochondrial damage that accu-
mulates with time (see below) is caused by f r e ~ d i c a l
reactions initiated by them, some would be expected to
result from nucDNA mutations that have deleterious
effects on mitochondrial function, thereby fu~her de-
creasing ATP I~roduction and increasing tl~ rate of
formation of the'superoxide radical and H202.
The increase in mitochondrial damage with age is
reflected in:
1) the inverse relationship between mitochondrial
superoxide radical and H202 production and lon-
gevity of: a) mammalian species (219), and b)
comparable size mammals and birds (220,221)
birds divert a smaller fraction of the oxygen they
consume to H202 and the superoxide radical than
do mammals
2) the decline in mitochondrial respiratory chain func-
tion in liver (222), skeletal muscle cells (223), and
brain (224) with age
3) the accumulation of mitochondrial DNA mutations
with age (225-227} - - the ra'{'e of accumulation is
higner in cells with higher metabolic rates and
increases with age (225,227), apparently expo-
nentially (225), so that eventually the percentage
of mtDNA molecules with one or more mutations in
a cell may exceed the threshold levels of about 60-
80 percent associated with cellular dysfunction
(225).
Mitochondrial DNA mutations arise at random, more
or less continuously, in cells (76,211-214,217-227). In
an adult these changes throughout the body are re-
flected in essentially "even" aging. However, a mtDNA
mutation during development may result in "uneven"
aging owing to faster aging of some descendants of the
progenitor cell. During cell division mitochondria are
allotted to the daughter cells at random. Clonal expan-
sion of the progenitor cell(s) results in a spectrum of cells
in which some cells have many copies of the mutated
mtDNA while others may have none (228,229). If muta-
tio0 of a mitochondfial DNA molecule occurs prior to
formation of the three germ cell layers it can cause a
systemic disorder as daughter cells throughout the
developing organism may have variable numbers of the
mutat~imtDNA and thus age at a normal rate or faster.
Data on mitochondrial disorders (228-235) suggest that
factors determining the percentage of abnormal mtDNA's
in a aiven dauahter cell include those listed in Table 6.

Table 6. Factorswhich influencethe percentageof mutatedmtDNA
moleculesin a daughtercelt include:
1. Clonal expansionof a cell in which a mutation has occurred in a
mltochondrialDNA molecule,resultsin a spectrumof cellsin which
some daughters have manycopiesof the mutated mtDNAwhile
others may havenone.The numberof copiesin cellsat the peakof
the sectrum increaseswith continued cell division, i.e.. clonal
expansion.
2. Natureof the mtDNAmutation,e.g.,mtDNAwithdeletions,because
they are shorter, replicatefasterthan normal and thus tend to
increasein numberswith timein a mitochondria.
3. Natureof the daughtercell. Lossof the mutatedmtDNA,e.g., by:
a) lysosomalremovalof abnormalmitoehondria
b) frequent cell division that results in selection againstcells
containingdefectivemitochondria.
Daughters of a progenitor cell with a nucDNA mutation
that has an adverse effect on mitochondrial function
have mitochondria that are all equally defective and age
faster than normal cells.
Precisely what determines the distribution of daughter
cells is not known; a beginning is being made (236-238).
Studies of mitochond,fial disorders demonstrate that a
mutation in a mtDNA - - or in a nucDNA molecule that
has an adverse effect on mitochondrial function, in a
progenitor cell early in development can result in daugh-
ter cells in the brain in sufficient number to cause clinical
symptoms, including dementia (228).
Superimposed on the above distribution of impaired
mitochondria, i.e., one that results from a mtDNA or
nucDNA mutation in a progenitor cell early in life, are the
mutations in mtDNA molecules throughout the body that
arise with advancing age (225-227) as well as those in
nucDNA that have adverse effects on mitochondria.
a.2) Pathogenesis
The first step in the pathogenesis of late onset,
sporadic SDAT is hypothesized to be a mutation(s)
early in development (blastocyst stage or before)
in a mtDNA molecule and/or in the nucDNA of the
precursor cell(s) for neurons associated with
Alzheimer's disease, that impairs oxidative phos-
phorylation and increases production of superox-
ide radical and H202; the usual result of damage
to mtDNA (211,228) and of mutations in nuclear
genes that influence mitochondrial function (228).
For example, the mutation(s) responsible for the
depressed cytochrome oxidase of platelet mito-
chondria found in five out of a group of six
Alzheimer's patients (17).
Mutations have been found in mtDNA in the
brains of individuals with Alzheimer's disease:
1) tRNA e~ variant present in the mitochondria ot
5.2 percent of SDAT patients as compared tc
0.7 percent in controls (239)
2) point mutations in codon 331 of mitochondrial
NADH dehydrogenase subunit 2 (ND 2) de-
tected in 10 of 19 Alzheimer's brains (240).
In accord with the above hypothesis,
Alzheimer's disease brains in which mutations
were found were heteroplasmic, i.e., the cells
contained both normal and mutated mtDNA.
104
Neuronal descendants in the brain of a pro-
genitor celt that had a mutated mtDNA are likely
to have different numbers of impaired mtDNA's
and therefore to be aging at different rates, owing
to differences in falling ATP productio n and pro-
gressively increasing rates of formation of super-
oxide radical and H202 by the mitochgond4~iawith
age. In contrast, all daughter cells of a progenitor
cell with a nucDNA mutation affecting mitochon-
drial function age at the same rate, hot at one
faster than normal.
As daughters of a progenitor cell wit'f'rimpaired
mitochondria, present in the brain .as neurons,
age to become dysfunctional and die, they would
be expected to contribute t ~ variable,~grees
depending on number, extent of rgitochondrial
impairme6t, and distribution - - to the early ap-
pearance of patterns of progressive, constantly
changing cognitive and noncognitive symptoms,
i.e., Alzheimer's disease.
The distribution of some descendant neuronal
cells with higher than usual numbers of impaired
mtDNA's is probably responsible for the early
atypical focal clinical presentations that occur in
about 10 percent of patients (1,13); these may
predominate for up to 4 years before the more
typical generalized deficit is apparent.
The suggested pathogenesis of Alzheimer's
disease caused by a mtDNA mutation is pre-
sented diagrammatically in Figure 1; the patho-
genesis due to mutations in,nuclear DNA genes
that influence mitochondrial function is similar.
The relatively late age of onset of clinical ex-
pression suggests that the mtDNA mutation(s)
and/or those in nuclear DNA affecting mitochon-
dria in the progenitor cell have only a mild de-
pressing effect(s) on mitochondrial functions.
Judging from the prevalence of this disorder--it
increases exponentially from essentially zero at
about age 60 to reach a value of around 10
percent at age 80 (9) w the mutation(s) in mtDNA
and/or nucDNA postulated to cause it occur at a
much higher rate than those of the rare, well-
known mitochondrial disorders (228-235) such
as the Kearns-Sayre syndrome (232); the latter is
attributed to mutation of a mtDNA molecule in a
somatic cell during development and is charac-
terized by onset before 20 years of age of
ophthalmoplegia, atypical retinitis pigmentosa,
mitochondrial myopathy, and oneof the follow-
ing: cardiac conduction defect, cerebellar dys-
function, or elevated cerebrospinal fluid protein.
a.3) Apolipoprotein E
~here is a positive association of apolipoprotein
isoforms, particularly apoE4, with late onset
fa~rnilialand sporadic SDAT (140,241-243); not all
older individuals with apoE4 alleles develop SDAT
(241). This suggests that the probability of a
mtDNA and/or nucDNA mutation may be in-
 120

Relativenumberof
mutatedmt DNA's
per cellat birthas a
resultof clonalexpansion
Normal SDAT
i 100

Neurons 0 4 80 _=>"
Leukocytes 0 1 Heightof arrowrepresents
relativelevelof 02";
Platalets 0 1 productionper averagecell
Cellwith
mutatedmt DNA Cellswithoneor more(darker) r
he progenitorcell) mutatedmt DNA'S
,0~ Ecloderm / Normal------] r :

""O ~"
Blastocyst /
/ wO13-OTO'o~
Mesoderm
' ~-
Threegermcell
layerstage
'i 20
=!

-37 -:35. . . . . . . . . . . -/P;!" '~ k~ ["~ ~ '; 100

Age (week=) ~ ~ ~ ~~ ( y
/ f I _~ Mltochondrta(mt) with
{ .. I_-_.E,~a mutatedDNA ( i"
'~T ~'The progenitorcell
BlastocystCell Cells showingrelativenumbersof mitochondriawithmutatedDNA's

Figure 1. Proposed pathogenesis of sporadic senile dementia of the AIzheimer's type. Upper left: a blastocyst
cell with a mutated mtDNA undergoes clonal expansion, resulting in daughter cells in the "three germ cell
stage" having one or more mutated mtDNA's per cell, and at birth a disproportionately greater number in the
neurons associated with SDAT. Bottom: the left half of the blastocyst cell depicted on the far left represents
a normal cell, the right half, a SDAT cell with a mutated mtDNA; on the dght side of the figure the number of
mutated mtDNA's in the normal and SDAT cells increase with age due to new mutations in mtDNA's. Right
upper half: the height of the arrows represents relative rates of production of the superoxide free radical,
deaths/1000 per year for SDAT and normal individuals, as well as the relative numbers of neuron~ deaths/
year in the areas associated with SDAT for the two populations. These values increase exponentially with
age.

creased owing to a possible higher metabolic rate
when the triglyceride-rich very low-density and
intermediate-densitylipoproteins associated with
apoE4 (140,244) are targeted to cells, and less so
by the triglyceride-poor high-density lipoprotein
(HDL) particles associated with apo E3.
The association with apolipoprotein E may also
be due in part to more rapid aging of "normal
neurons", as well as those of sporadic SDAT, in
the presence of the compound. ApoE increases
conversion by co-oxidation - - faster with apoE4
than with apoE3 (140,141), of fibrils present in
diffuse plaques to toxic forms that stain with
Congo red.
a.4) Aluminum
Aluminum may also be a risk factor. The alumi-
num content of drinking water is positively associ-
ated with the incidence of SDAT (201); this asso-
ciation is disputed (202,203). Aluminum can react
with DNA (189). A aluminum-induced mitochon-
drial mutation early in development could account
for the epidemiologic data and not be in conflict
with the aluminum studies discussed above which
fail to show an association with SDAT.
b) Late onset, familial SDA T
This SDAT category is probably small: it may be
a result of inherited factors that modulate the rate
ofl3Apeptide aggregation (132,136-141) to forms
(160-163) that enhance aging in "normal neu-
rons" by increasing H202 formation (164). Some
cases may have inherited a chromosomal defect
that impairs mitochondrial function which is clini-
cally expressed late in life.
c) Early onset, sporadic SDA T
Small SDAT category - - thus far no reported
cases.
d) Early-onset, familial SDA T
These autosomal dominant disorders, about 5-
10 percent of all SDAT cases, may also be a
consequence of increased oxidative stress. Al-
most all families are associated with mutations on
either chromosome 14 (5) (the gene products are
not known), chromosome 1 (6) (gene products
unknown), or chromosome 21 (mutations of the
~myloid precursor protein) (7).
d.1 ) Chromosome 14 assoctated families
The majority of early-onset cases are linked with
mutations on chromosome 14 (5). The gene

105
 involved has been identified and designated S 182
(245); 5 missense mutations have been found
the gene products have not been isolated. Muta-
tions in the $182 gene probably have deleterious
effects on mitochondrial function; this is depressed
(hence mitochondrial aging is increased - - see
above) in fibroblasts from early-onset familial
patients (14) - - the chromosomes involved in
these patients are not known, since most cases
have mutations on chromosome 14 thedata most
probably reflect the function of fibroblasts with
mutations in the $182 gene.
d.2) Chromosome 1 associated families
The autosomal dominant locus in the Volga Ger-
man (VG) kindreds is on Chromosome 1 (6). A
candidate gene has been identified and named
STM2 (246); a point mutation resulting in substi-
tution of an isoleucine for an asparagine was
identified in affected members (246).
The gene STM2 is 67 percent homologous to
$182 (246); this suggests that it also causes
mit0chondrial dysfunction. The genes STM2 and
$182 are similar to the C. elegans gene spe4
(247). Proteins encoded by these three genes
are predicted to be integral membrane proteins
and to contain at least seven transmembrane
domains. The predicted protein of the spe4 gene
seems to be involved in the formation and stabi-
lization of the fibrous body-membrane organelle
complex during spermatogenesis (247) in C.
elegans..
In view of the above, a possible function of the
proteins encoded by the STM2 and S182 genes
may be to ensure the proper positioning of mito-
chondrial components, e.g., by serving as "dock-
ers". If so, mutations in these nuclear genes could
cause mitochondrial dysfunction with formation
of increased amounts of superoxide radical and
H202. This could account, at least in part, for the
relatively early age of onset, aS compared to that
of late onset, sporadic SDAT; all the mitochondria
of individuals associated with Chromosomes 1
and 14 should be aging faster than normal while
this would be true for only a fraction of the
mitochondria of late onset patients.
d.3) Chromosome 21 associated families
Oxidative stress may be higher in these families
secondary to increased turnover (72) of the ab-
normal APP and/or to increased formation of ~A
peptide. Human neuroblastoma cells transfected
with a construct expressing a mutant APP (248)
had five times more of an AI3-beadng, carboxyl
terminal, APP derivative than cells expressing
wild-type APP and they released six times more
l~A peptide into the medium. Mice transgenic for
13APP751 also produced more!3A peptides (249);
older mice displayed behavioral abnormalities
(250). Increased formation of 13A peptide could
106
increase the chance that aggregated 1313Apep-
tides (160-163) would perturb: 1) neuronal mem-
branes so as to enhance cellular formation of
H202 (164), and 2) microglial membranes to cause
production of NO (173-175).
2. Down's syndrome
This syndrome is associated with three copies of
chromosome 21 rather than the normal two. Chro-
mosome 21 codes for both SOD and APP; these
gene products are increased in the cells of individu-
als with Down's syndrome (251). Persons with this
disorder display premature aging (251,252); mani-
festations include rapid aging of the skeletal system
and skin, early menopause, short life span, and
SDAT-like pathology (172) after about age 40. The
first indication of the latter is generally apathy (251)
and recent r~emory loss (253). In view of the discus-
sion above, familial SDAT cases associated with
chromosomes 1 and 14 may also display acceler-
ated aging; published reports focus only on central
nervous system manifestations. The premature
aging of Down syndrome patients is probably caused
by a higher than normal level of oxidative stress in
the cells. The latter is indicated by:
1) increased lipid peroxidation in PC12 (254),
mouse L (255), and human HeLa (255) cells
transfected with human Cu/Zn superoxide
dismutase
2) higher than normal levels of superoxide dis-
mutase (256) in cultured fibroblasts
3) increased activities of glucgse-6-phosphate de-
hydrogenase (257) in erythrocytes
4) enhancedactivityofglutathioneperoxidase(257)
in erythrocytes and in cultured fibroblasts
Thus, the early appearance of normal neuronal
dysfunction and loss in the brains of individuals with
Downs syndrome may be caused by a higher than
normal rate of cellular aging in the brain - - as well
as throughout the body, owing to increased forma-
tion of both superoxide dismutase and APP (with
enhanced formation of ~A peptides) by their cells.
3) Dementia pugilistica (DP)
A blow(s) to the head is a risk factor for Alzheimer's
disease (258). Was the head injury President
Reagan received in 1989 in a fall from a horse
responsible for his diagnosis of Alzheimer's dis-
ease in 1994? Repeated blows to the head are
associated with DP - - the punch drunk syndrome
(259,260). The severity of the syndrome correlates
with the length of the boxing career and total num-
ber of bouts, and has an overall incidence of about
17 percent in professional boxers which rises with
age (259,260). There are numerous neurofibrillary
tarries in the cerebral cortex, particularly in the
temporal lobe (259,260). In contrast to SDAT, neu-
ritic plaques are few while diffuse preamyloid plaques
(259) are abundant; the diffuse plaques can form
 Ioo, 1

Bo-

70-

Z
>60- ->,
u 50-
~t
40.

30' ~ CONTROL {]31} 30. = .; C O N ~ O L c~:,o) !,~

O--.O 0 ~ , ~ w S A N T O Q U I N ($]} o-o c,,I
t MA~S
0 5%w 2-MEA IC~5)
20 J-,el ~oW Nc~IP {50) 20- JLt~

10- 10- " ~

0 5 10 15 20 25 30 35 40 0 .5 tO 15 20 25 30 35 ,X)
AGE. MONTHS AGE. MOf,ITH$
Figure 2. Effect of adding antioxidantsto the maternal diet on the average life span of offspring: A - - males; B - - females.The average
life span of male offspringof mothers receiving0.5 percent by weight of 2-mercaptoethylamine(2-MEA) in the diet was 15 percent greater
than those whose mothers had only receivedthe control diet; the correspondingvalue for female offspring was 8 percent (the 7 percent
difference is believed relatedto the gender difference in longevity[210, 271 ]). These data confirmedthe results of an earlier study.

within days after head injury (261). Most cases
show evidence of past brain hemorrhage (262).
The initiating steps in pathogenesis of DP may be
similar to those of late onset, sporadic SDAT. Ex-
tracellular iron, e.g., in the form of heme, may
disrupt calcium homeostasis by increasing the in-
flux of calcium through the neuronal membrane by:
1) catalyzing oxidative alterations in the membrane,
and 2) increasing intracellular H202 concentrations
(by catalyzing the aggregation rate of extracellular
!3A peptides to form amyloid, this in turn perturbs the
neuronal membrane so as to activate an NADPH
oxidase). The relative paucity of neuritic plaques
can be related to a low level of free radical reactions
in the celt, in comparison to that in the senescent
cells of SDAT, coupled with a corresponding lower
cellular level of proteases. Thus, as the axonal
terminals disintegrate the oxidative/proteolytic ac-
tivity may not be high enough to form neuritic
plaques - - even though catabolic enzymes may be
activated to the same degree as with SDAT.
4) Parkinson's disease
The pathogenesis of idiopathic Parkinson's disease
may be similar to that of late onset sporadic SDAT; a
defect has been found in Complex I of mitochondria from
platelets (263.264) as well as in the substantia nigra (265)
of patients with Parkinson's disease. Defective mitochon-
dria have also been found in the skeletal muscle of such
patients (266.267): a similar study apparently has not
been conducted with Alzheimer's disease patients.
The frequent overlap in clinical manifestations be-
tween the two disorders (268-270) may be largely due to
overlap in the tissue distribution~of daughters of the
progenitor cells.
PREVENTION AND TREATMENT
The hypothesis that increased free radical reaction
levels in brain neurons causes Alzheimer's disease, as
well as the similar disorder observed in Down's syn-
drome and dementia pugilistica, is suggestive of mea-
sures to prevent and treat.
Alzheimer's Disease
Late onset, sporadic SDA T
The incidence maybe decreased by efforts to mini-
mize free radical reactions involved in the disorder. For
example, decreasing maternal deleterious free radical
reactionsby dietary modulation and/or antioxidant supple-
ments such as vitamins C and E, Coenzyme Q~0, and 13-
carotene. A part of the increased longevity of mice fed a
normal diet (Figure 2) whose mothers had antioxidants
added to their diet throughout pregnancy and until
weaning (271), may have been due to decreased muta-
9 Jl
hons in mtDNA and/or nucDNA molecules; the antioxi-
dants did not have any apparent adverse effects on the
pregnancies.
When the disorder is detected, the rate of free radical
damag e to involved neurons may be by decreased by
lowering the level of more-or-less random free radical
reactions by a combination of the following measures:

107
 1) decrease free radical initiation rates
a) lower caloric intake to an acceptable level (210)
b) add suitable spin-traps (272,273) to the diet;
these are nitrones or nitroso compounds which
react with free radicals to form relatively stable
nitroxides - - they can compete with 02 for
electrons from the mitochondrial respiratory
chain to form hydroxylamines(210, 273)
2) supplementing the diet with antioxidants such as
vitamins C and E, and 13-carotene
3) dietary supplementation with compounds employed
to improve mitochondfial function (228,235,274);
e.g., riboflavin 275), menadione (276), and Coen-
zyme Q~: (277).
Familial SDA T
Chromosomes 1 and 14
In the absence of gene therapy, these cases of SDAT
can not be prevented.
Treatment - - as with late onset, sporadic SDAT.
Chromosome 21
Prevention and treatment-- as with chromosomes 1
and 14.
Down's Syndrome
Can only be prevented by measures, presently not
available, that ensu re separation of the two homologs of
chromosome 21 during the nuclear division of the matur-
ing oocyte in meiosis I.
If detected during pregnancy, the disorder may be
ameliorated by decreasing the level of more-or-less
random free radical reactions by: 1) lowering maternal
initiation rates by decreasing caloric intake to an accept-
able level and by adding spin-traps (if they are shown to
be safe) to the maternal diel, and 2) supplementing the
maternal diet with antioxidants. After birth, the measures
suggested for late onset, sporadic SDAT should be
beneficial.
Parkinson's Disease
Prevention and treatment-- as with late onset, sporadic
SDAT.
Dementia Pugilistica
Prevention - - measures to prevent injuries to the head.
Treatment - - as with late onset, sporadic SDAT.
COMMENT
The hypothesis that late onset, sporadic SDAT is caused
by a mutation(s) ~n a mitochondrial DNA molecule and/
or in the nucDNA of a somatic cell early in development
accounts for the major aspects of the disorder, including:
1) systemic nature of SDAT; daughter cells are de-
rived from both the ectoderm (neurons) and meso-
derm (fibroblasts, platelets, red blood cells) germ
cell layers
2) major risk factor is age; loss/dysfunction of normal
neurons associated with SDAT increases with age
this normal process is enhanced in daughter
cells
108
3) lesions are identical to those seen normally at a
later age in the general population; generally the
same cells are involved but they are aging at a
faster rate
4) the constantly changing patterns of cognitive and
noncognitive symptoms; reflects the number, dif-
ferences in aging rates, and distribution of daugh-
ter cells in the brain
5) atypical clinical presentations occur in about 10
percent of patients; caused by an atypical distribu-
tion of daughter cells or by a small fraction that are
aging significantly faster than the othe~
Most case of late onset, sporadic SDAT are probabl~
caused by mutation(s) in mtDNA molecules rather than
in nucDNA because daughter cells with a spectrum of
aging rates may better account for items 4 ~l'Sd5 above,
than could those whose aging rates are a~i equal.
Antioxidant supplementation by the general popula-
tion may decrease the incidence by disproportionately
slowing the rate of free radical reaction damage to
neurons associated with Alzheimer's disease in indi-
viduals destined to develop the disorder. Such supple-
mentation may also decrease the rate of neuronal dys-
function and cell loss in the population as a whole by
minimizing the adverse effects of increases in neuronal
H202 induced by I3A peptide aggregation on the cell
membrane and/or, possibly, by NO produced by 13A
peptide-activated microglial cells.
In the light of the above hypothesis and discussion,
prospects for prevention and treatment of Alzheimer's
disease and related disorders appear good.
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