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Alternative Medicine Review Volume 13, Number 2 2008   Review Article                                        Alzheimer’s D...
Alternative Medicine Review Volume 13, Number 2 2008                                                                      ...
Alternative Medicine Review Volume 13, Number 2 2008   Review Article   must be sufficiently severe to cause impairment in...
Alternative Medicine Review Volume 13, Number 2 2008                                                                      ...
Alternative Medicine Review Volume 13, Number 2 2008   Review Article   the regulation of blood flow, extraction of oxygen...
Alternative Medicine Review Volume 13, Number 2 2008                                                                      ...
Alternative Medicine Review Volume 13, Number 2 2008   Review Article             Reactive oxygen species (ROS) and reacti...
Alternative Medicine Review Volume 13, Number 2 2008                                                                      ...
Alternative Medicine Review Volume 13, Number 2 2008   Review Article              Memantine (Namenda®) is an NMDA-re-    ...
Alternative Medicine Review Volume 13, Number 2 2008                                                                      ...
Alternative Medicine Review Volume 13, Number 2 2008   Review Article                Figure 3B. Glycerophosphocholine: One...
Alternative Medicine Review Volume 13, Number 2 2008                                                                      ...
Alternative Medicine Review Volume 13, Number 2 2008   Review Article            Cold-water fish are the best dietary sour...
Alternative Medicine Review Volume 13, Number 2 2008                                                                      ...
Alternative Medicine Review Volume 13, Number 2 2008   Review Article            A 2005 meta-analysis by the Cochrane grou...
Alternative Medicine Review Volume 13, Number 2 2008                                                                      ...
Morbo di Alzheimer, disturbi cognitivi amnesici leggeri, e disturbi della memoria associati all’età: conoscenze attuali e ...
Morbo di Alzheimer, disturbi cognitivi amnesici leggeri, e disturbi della memoria associati all’età: conoscenze attuali e ...
Morbo di Alzheimer, disturbi cognitivi amnesici leggeri, e disturbi della memoria associati all’età: conoscenze attuali e ...
Morbo di Alzheimer, disturbi cognitivi amnesici leggeri, e disturbi della memoria associati all’età: conoscenze attuali e ...
Morbo di Alzheimer, disturbi cognitivi amnesici leggeri, e disturbi della memoria associati all’età: conoscenze attuali e ...
Morbo di Alzheimer, disturbi cognitivi amnesici leggeri, e disturbi della memoria associati all’età: conoscenze attuali e ...
Morbo di Alzheimer, disturbi cognitivi amnesici leggeri, e disturbi della memoria associati all’età: conoscenze attuali e ...
Morbo di Alzheimer, disturbi cognitivi amnesici leggeri, e disturbi della memoria associati all’età: conoscenze attuali e ...
Morbo di Alzheimer, disturbi cognitivi amnesici leggeri, e disturbi della memoria associati all’età: conoscenze attuali e ...
Morbo di Alzheimer, disturbi cognitivi amnesici leggeri, e disturbi della memoria associati all’età: conoscenze attuali e ...
Morbo di Alzheimer, disturbi cognitivi amnesici leggeri, e disturbi della memoria associati all’età: conoscenze attuali e ...
Morbo di Alzheimer, disturbi cognitivi amnesici leggeri, e disturbi della memoria associati all’età: conoscenze attuali e ...
Morbo di Alzheimer, disturbi cognitivi amnesici leggeri, e disturbi della memoria associati all’età: conoscenze attuali e ...
Morbo di Alzheimer, disturbi cognitivi amnesici leggeri, e disturbi della memoria associati all’età: conoscenze attuali e ...
Morbo di Alzheimer, disturbi cognitivi amnesici leggeri, e disturbi della memoria associati all’età: conoscenze attuali e ...
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Morbo di Alzheimer, disturbi cognitivi amnesici leggeri, e disturbi della memoria associati all’età: conoscenze attuali e progresso verso la prevenzione integrativa

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Morbo di Alzheimer, disturbi cognitivi amnesici leggeri, e disturbi della memoria associati all’età: conoscenze attuali e progresso verso la prevenzione integrativa

  1. 1. Alternative Medicine Review Volume 13, Number 2 2008 Review Article Alzheimer’s Disease, Amnestic Mild Cognitive Impairment, and Age-Associated Memory Impairment: Current Understanding and Progress Toward Integrative Prevention Parris M. Kidd, PhD Abstract other antioxidants. A comprehensive integrative strategy Alzheimer’s disease (AD) is the most common form of dementia. initiated early in cognitive decline is the most pragmatic AD initially targets memory and progressively destroys the mind. approach to controlling progression to Alzheimer’s disease. The brain atrophies as the neocortex suffers neuronal, synaptic, (Altern Med Rev 2008;13(2):85-115) and dendritic losses, and the “hallmark” amyloid plaques and neurofibrillary tangles proliferate. Pharmacological management, Introduction at best, is palliative and transiently effective, with marked Alzheimer’s disease (AD) is a devastating dis- adverse effects. Certain nutrients intrinsic to human biochemistry ease that takes away the very essence of a person – their (orthomolecules) match or exceed pharmacological drug sense of self. AD, the most prevalent form of dementia, benefits in double-blind, randomized, controlled trials (RCT), accounts for 50-70 percent of dementia cases1 and sig- with superior safety. Early intervention is feasible because its nificantly impacts patients, families, caregivers, commu- heritability is typically minimal and pathological deterioration nities, and society as a whole. Current medical manage- ment of AD is ineffectual, with no cure on the horizon. is detectable years prior to diagnosis. The syndrome amnestic Conventional medicine has little to offer for mild cognitive impairment (aMCI) exhibits AD pathology and to Alzheimer’s disease. The five pharmaceutical drugs ap- date has frustrated attempts at intervention. The condition age- proved in the United States as primary AD therapies associated memory impairment (AAMI) is a nonpathological can slow the progression of some symptoms, but gen- extreme of normal brain aging, but with less severe cognitive erally only for 6-12 months;2 half of all patients may impairment than aMCI. AAMI is a feasible target for early show no improvement. A number of nutrients studied intervention against AD, beginning with the modifiable AD risk in double-blind, randomized clinical trials (RCTs) have factors – smoking, hypertension, homocysteine, type 2 diabetes, shown significant efficacy and safety. Nevertheless, the insulin resistance, and obesity. Stress reduction, avoidance of AD diagnosis comes at such an advanced stage of neu- toxins, and mental and physical exercise are important aspects rodegeneration, and the disease progression is so unre- of prevention. The diet should emphasize omega-3 fatty acids mitting, that chances for its eventual effective manage- docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA); ment seem remote. flavonoids and other antioxidant nutrients; and B vitamins, Parris M. Kidd, PhD — Cell biology; University of California, Berkeley; contributing especially folate, B6, and B12. Dietary supplementation is editor, Alternative Medicine Review; health educator; biomedical consultant to best focused on those proven from RCT: the phospholipids the dietary supplement industry Correspondence address: 10379 Wolf Drive, Grass Valley, CA 95949 phosphatidylserine (PS) and glycerophosphocholine (GPC), Email: dockidd@dockidd.com the energy nutrient acetyl-L-carnitine, vitamins C and E, and Page 85Copyright © 2008 Thorne Research, Inc. All Rights Reserved. No Reprint Without Written Permission. Alternative Medicine Review Volume 13, Number 2 June 2008
  2. 2. Alternative Medicine Review Volume 13, Number 2 2008 Alzheimer’s Disease Despite this pessimistic scenario there are rea- Subsequently, Alzheimer described a second sons for optimism. Intensive research is in progress on case, that of Johann F., whose brain differed in that it every aspect of the disease. The main emphasis is on lacked NFT – a “plaque-only” case. Such cases remain early intervention. Techniques have recently become part of the modern disease type.4 These two initial available that accurately detect a likely prodrome of AD, cases, published as “presenile dementia” by Alzheimer, called amnestic mild cognitive impairment (aMCI), later became labeled Alzheimer’s disease by Kraepelin.4 which is considered pathological. Another condition, Miraculously, histological slides of both cases have sur- age-associated memory impairment (AAMI), is a non- vived to the present, and modern re-examinations con- pathological condition that also carries heightened risk firm Alzheimer’s original findings.4 for progression to AD. AAMI, an extreme of normal aging, is less severe than aMCI and consequently offers Framework for the Alzheimer’s Disease more promise for successful early intervention. Diagnosis This review discusses the current medical The term “dementia” refers to a group of disor- management of AD, efforts at early detection and inter- ders that cause cognitive decline as a result of death or vention of aMCI, and the possibilities for primary pre- damage to brain cells. By definition, dementia causes a vention of AAMI. The many established and putative decline in at least two of four essential cognitive func- risk factors for AD are catalogued. A comprehensive, tions: (1) memory; (2) ability to speak or understand multimodal, early intervention strategy appears to be language; (3) capacity to plan, make sound judgments, the most pragmatic approach to controlling Alzheimer’s and carry out complex tasks; and (4) ability to process disease and takes advantage of the best features of inte- and interpret visual information. The decline must be grative medicine. severe enough to interfere with day-to-day life.1,5 The typical Alzheimer’s symptom pattern be- What is Alzheimer’s? The Disease and its gins with memory loss for recent events (short-term Progression memory).1,5 Pathologically, amyloid plaques and neu- Historical Perspective rofibrillary tangles are still its hallmarks. Since these In 1901, the German psychiatrist and neu- cannot be definitively identified until autopsy, the Al- ropathologist Aloysius Alzheimer first observed a zheimer’s diagnosis remains one of exclusion. 51-year-old patient, Auguste D., who was plagued by The most widely accepted diagnostic criteria symptoms that did not fit any existing diagnosis: rapidly for probable AD were developed by the U.S. National failing memory, confusion, disorientation, trouble ex- Institute of Neurological and Communicative Disor- pressing her thoughts, and unfounded suspicions about ders and Stroke and by the Alzheimer’s Disease and her family and the hospital staff. His patient progressed Related Disorders Association joint-working group.6 inexorably, one day saying to Dr. Alzheimer, “I have lost These specify that dementia be established by clinical myself.”3 examination and confirmed by neuropsychological test- Alzheimer performed an autopsy on Auguste ing. The dementia should involve multiple, progressive D. upon her death, after four years of steady decline that cognitive deficits in older persons in the absence of oth- left her bedridden and mute. Autopsy revealed a dra- er medical, neurological, or psychiatric conditions that matically shrunken brain but no evidence of atheroscle- might account for the deficits. rosis. Nissl silver staining histology of the brain yielded The U.S. Diagnostic and Statistical Manual, 4th widespread dead and dying cells and two microscopic Edition, Text Revision (DSM-IV-TR)5 offers a step- deposits that have become hallmarks of the disease: wise diagnosis of AD. The first step in the progression “plaques” (amyloid plaque) and “tangles” (neurofibrillary is memory loss. Second, at least one other cognitive def- tangles or NFT), located in the upper cortical layers. icit occurs, including aphasia (language deterioration), The deeper hippocampus and entorhinal region were apraxia (motor difficulties), agnosia (failure to recog- not sampled.3 nize objects despite intact sensory capacity), or a distur- bance in executive functioning. These cognitive deficits Page 86Copyright © 2008 Thorne Research, Inc. All Rights Reserved. No Reprint Without Written Permission. Alternative Medicine Review Volume 13, Number 2 June 2008
  3. 3. Alternative Medicine Review Volume 13, Number 2 2008 Review Article must be sufficiently severe to cause impairment in oc- Of Americans over age 65, 13 percent – one cupational or social performance (e.g., going to school, in eight – have AD; over age 85, as many as 50 percent working, shopping, dressing, bathing, handling finances, are afflicted. Every 72 seconds someone in the United and other activities of daily living), and must represent States develops Alzheimer’s disease. The Association a decline from a previous level of functioning. predicts this number will swell as the “baby boomer” Disturbances in executive functioning are com- generation approaches age 65. AD is the fifth leading mon in AD. The DSM-IV-TR defines executive func- cause of death for people age 65 and older.1 tioning as “the ability to think abstractly and to plan, Of the 4.9 million cases of late-onset or “spo- initiate, sequence, monitor, and stop complex behav- radic” AD (idiopathic; cause or causes unknown), by ior.”5 The individual has trouble coping with novel tasks age group:1 and avoids situations that require the processing of new and complex information. Tests for executive function ÂÂ Age 65-74: 300,000 (2 percent) include asking the individual to count to 10, recite the ÂÂ Age 75-84: 2,400,000 (19 percent) alphabet, subtract serial 7s, state as many animals as ÂÂ Age 85+: 2,200,000 (42 percent) possible in one minute, or draw a continuous line con- sisting of alternating m’s and n’s. Often the individual or To date, late-onset AD shows no substantial the individual’s caregivers report difficulty with ability gene linkage, with the notable exception of apolipopro- to work, plan daily activities, budget, and so on. tein E4 gene (ApoE4), which is firmly implicated as an The DSM-IV-TR emphasizes that, to reach a AD risk factor. Both heterozygous and homozygous in- diagnosis of probable Alzheimer’s disease, various other dividuals are at higher risk for AD, with homozygotes dementia etiologies must be ruled out. Delirium can having the highest risk. Still, of ApoE4/4 individuals, cause memory impairment, but typically is less stable half do not develop AD. and long-lasting than dementia. Severe memory impair- The institutional cost of caring for AD patients ment without other cognitive involvement qualifies as an is three times that for people without dementia.1 In the amnestic disorder but not as dementia. The diagnosis of United States more than 70 percent of Alzheimer’s vascular dementia is attributable to circulatory dysfunc- patients are cared for at home, and the average patient tion or disease. HIV infection, encephalitis, and stroke lives 8-20 years after being diagnosed. The Alzheimer’s can cause dementia due to other general medical con- Association data suggest that for the year 2005 (most ditions. Substance intoxication or withdrawal can lead recent available), total cost to the national government, to substance-induced persisting dementia. When these states, the healthcare sector, and lost productivity ap- are ruled out, dementia of the Alzheimer’s type can be proached $300 billion.1 considered, provided the history includes gradual onset and continuing decline.5 The Pathophysiology of Alzheimer’s Disease Prevalence of Alzheimer’s Disease At autopsy the Alzheimer’s brain displays The Alzheimer’s Association of the United widespread changes, including atrophy (Figure 1).9-11 States in its 2007 Facts and Figures report1 estimates 5.1 The folds of the brain’s outer layer (gyri) are shrunken, million Alzheimer’s cases. Of these, only about 200,000 and the grooves (sulci) are noticeably widened. The (4%) occur in people younger than age 65 – designated ventricles, chambers within the brain containing cere- as early-onset Alzheimer’s disease, known to be familial, brospinal fluid, are noticeably enlarged. Brain mass is and variously related to gene mutations. The remaining reduced up to one-third, attributable to significant loss 4.9 million cases (96 percent) occur at or over age 65 of nerve cells, synapses, and dendrites. Most of this cir- and are labeled late-onset AD.1 Prevalence in Europe cuit dropout occurs in the neocortex.9 By comparison, likely exceeds 4.8 million.7 Worldwide prevalence of the healthy brain suffers only modest loss of mass dur- AD is estimated at 18 million in 2008.8 ing aging.11 Page 87Copyright © 2008 Thorne Research, Inc. All Rights Reserved. No Reprint Without Written Permission. Alternative Medicine Review Volume 13, Number 2 June 2008
  4. 4. Alternative Medicine Review Volume 13, Number 2 2008 Alzheimer’s Disease Figure 1. The Healthy Brain (left) and the Alzheimer’s Brain (right) Hippocampus and Entorhinal Cortex The hippocampus and Healthy Advanced EC work in tandem for learning Brain Alzheimer’s and memory. The EC is neocor- Disease tical and is one of the first areas to show abnormalities, consis- tent with memory loss being one of the earliest symptoms of AD. The hippocampus can sustain extreme damage; by the time of death an Alzheimers patient may have lost virtually all the hip- pocampal CA1 cells crucial for memory formation.11 Amygdala The amygdala is a nucle- us located relatively deep in the cortex beneath the temporal lobe. It operates in coordination with This is a gross comparison of slices through the the EC and hippocampus and is middle of the brain between the ears. associated with emotional screen- Note the markedly smaller size of the Alzheimer’s brain. The folds and grooves of the outer layer are ing of information reaching the atrophied and the ventricles are larger. brain. As this zone deteriorates, From: the Alzheimer’s Association, © 2007 Alzheimer’s so also does the ability to appre- Association.org, www.alz.org. ciate the emotional significance Illustration by Stacy Jannis. Used with permission. of new experience.9 Several other small “nuclei” deeper in the brain also typically become afflicted, as Neocortical Degeneration discussed below.9 In humans the neocortex makes up most of the cortex. Approximately six cells thick, it is the outermost cortical zone.9 This zone encompasses the highest order Nucleus Basalis of Meynert (NBM) association areas that manage the most sophisticated A tiny nucleus on the rostral-most portion of cognitive processes. Amyloid becomes deposited in the the reticular formation, the NBM uses acetylcholine extracellular spaces within nerve tissue and in the blood (ACh) as its main chemical transmitter and has wide- vessel walls.10 This causes endothelial damage resulting spread projections to the cortex. The NBM’s function in cerebral amyloid angiopathy that can rupture arteries is unclear, but according to Norden its degeneration is and arterioles in the cortex. Such hemorrhages are often closely linked with the emergence of dementia.9 the cause of death for the AD patient.10 Because the inner areas of the cortex typi- Nucleus Locus Coeruleus (NLC) cally remain relatively intact, the senses are relatively The NLC is a tiny nucleus in the reticular for- preserved. However, as the limbic structures – the mation, a zone that utilizes norepinephrine as its main hippocampus, entorhinal cortex (EC), and amygdala neurotransmitter.9 Like the NBM, it too has direct pro- – progressively become involved, the individual loses jections to the cortex. The NLC has many functions in emotional capabilities. Page 88Copyright © 2008 Thorne Research, Inc. All Rights Reserved. No Reprint Without Written Permission. Alternative Medicine Review Volume 13, Number 2 June 2008
  5. 5. Alternative Medicine Review Volume 13, Number 2 2008 Review Article the regulation of blood flow, extraction of oxygen and 50 years or longer. Although more dense distribution glucose from the blood, and in selective attention. The of tangles (Braak stages V-VI) is usually thought to NLC also plays a major role in sleep-wake cycles. denote more severe Alzheimer’s symptomatology, the findings from the Nun Study suggest this correlation Raphe Nuclei does not always hold.15 The raphe nuclei are groups of serotonergic The Nun Study was initiated in 1986 by neurons in the reticular formation, extending from the Snowdon, who obtained the cooperation of the Catho- medulla to the midbrain.9 They also have massive pro- lic Order School Sisters of Notre Dame to do ongo- jections to the cortex. Current evidence indicates the ing functional assessments, blood sampling, and other raphe nuclei contribute to mood management. monitoring until the nuns died, then have access to their brains for study. This has become a landmark study and has yielded a wealth of information about brain aging, Blood-Brain Barrier (BBB) risk factors for AD (or lack thereof ), and correlates of In some AD patients the BBB becomes perme- Alzheimer’s disease with cognitive capacity, lifestyle, and able,12 allowing greater access of toxins or other harmful diet. The nuns in this study did not experience AD as a agents to the brain tissue. BBB failure has been linked consequence of aging; only 3 of 13 who surpassed age to accelerated disease progression and suggested as an 100 had severe AD pathology.15 Their spirituality, strong explanation for encephalitis linked to the ill-fated Al- positive community life, and near-pristine lifestyle all zheimer’s vaccine.12,13 seem to have contributed to a much lower incidence of AD than the general population. Snowdon noted the The Cell-Level Progression of Alzheimer’s nuns who had Alzheimer’s symptoms at death also had Disease micro-infarcts and other circulatory abnormalities in The brain zones affected in AD have signifi- the brain tissue.15 cantly lower nerve cell, dendrite branches, and synapse The nuns did not show a strong correlation densities. Throughout the tissue there is debris from of NFT distribution with symptomatology because, if damaged or dead cells, extracellular deposits of amy- infarcts were not apparent, they were cognitively intact loid, and previous intracellular tangles that can retain despite very dense NFT.15 For the general population, ghostly outlines after the cells disintegrate.9 Although however, postmortem examination, other histology, nondementia brains also exhibit amyloid and tangles non-invasive metabolic imaging techniques, and high- (especially with aging and the presence of the ApoE4 resolution MRI all correlate with the histologic pro- gene), the AD brain has quantitatively more plaques gression of Alzheimer’s gleaned from Braak staging. In and tangles. 2008, a European cooperative group of 25 experts con- The neurofibrillary tangles arise within indi- cluded Braak staging is 50-percent reproducible when vidual neurons as depositions of abnormally twisted fil- the tangles are mild (stages I-II), rising to 91 percent at aments. The tau protein normally is linearly organized stages V-VI.16 NFT distributions can now be imaged into microtubules that give scaffolding to the nerve cells. using positron emission tomography (PET) scans.17 In AD the tau proteins are excessively phosphorylated, Amyloid plaques are aggregates of beta-amy- causing them to form abnormally twisted filaments ag- loid (AB42), a protein found in plaques in the normal, gregated in tangles. Braak et al developed a system to healthy brain. AB42 is a large protein remnant from rate the extent and severity of tangles.14 The system the snipping of a larger protein (called amyloid precur- ranges from zero at baseline through six abnormal stag- sor or APP) by the enzyme gamma-secretase. AD tis- es. The first stage has been observed in people as young sue has more AB42, and in AD the single AB42 units as age 20.15 (monomers) are abnormally sticky, both factors thought It is believed tangles most often appear in the to promote abnormal amyloid plaque formation.10 Am- EC, near the base of the skull, and later spread to the yloid can also be accurately imaged using PET scans, hippocampus, then to the neocortex, which can take with a radio-labeled agonist for AB42.18 Page 89Copyright © 2008 Thorne Research, Inc. All Rights Reserved. No Reprint Without Written Permission. Alternative Medicine Review Volume 13, Number 2 June 2008
  6. 6. Alternative Medicine Review Volume 13, Number 2 2008 Alzheimer’s Disease Inflammation in the AD Cortex Figure 2. Serum Oxidative and Antioxidative Status of Alzheimer’s The brain demonstrates im- Patients versus Healthy Controls mune capability; at least 12 percent of the cells of the central nervous system are immune cells (mostly macrophages, + 2.0 100 known in the brain as microglia, and as- trocytes).19 In the AD brain, activated 90 * 1.8 microglia and astrocytes are concen- trated in the vicinity of amyloid plaques. + 1.6 Axons and dendrites in the immediate 80 * Serum Antioxidative Status 1.4 Serum Oxidative Status surroundings are often structurally ab- normal – a pattern suggestive of chronic 70 inflammation. 1.2 Evidence suggests AD involves 60 low-level chronic inflammation of the 1.0 brain’s gray matter.19 This inflammation 50 is likely stimulated by AB42 buildup 0.8 and is regulated by the resident micro- 40 glia and astrocytes, both of which can be 0.6 anti-inflammatory or proinflammatory 30 depending on activation state. Experi- 0.4 mental evidence suggests AB42 directly 20 damages nerve cells even as it activates 0.2 the microglia and the astrocyes.19 Details 10 of the inflammatory progression in AD 0 are not yet resolved, but may be more 0 atypical than first thought, especially AD Patients Controls since non-steroidal anti-inflammatory (n=22) (n=22) Serum Oxidative Status * = p<0.0001 drugs (NSAIDs) have not produced consistent benefit in controlled trials. Serum Antioxidative Status + = p<0.05 Oxidative Stress AD oxidative status was significantly greater versus controls, and Oxidative stress is clearly evi- antioxidative capacity significantly poorer than controls. dent in AD.20 Numerous oxidative stress Adapted from: van Rensburg SJ, van Zyl JM, Potocnik FCV, et al. biomarkers are elevated in the blood and The effect of stress on the antioxidative potential of serum: brain. The brain zones demonstrating the implications for Alzheimers disease. Metab Brain Dis 2006;21: highest levels of oxidative stress are typi- 171-179. Used with permission from Springer Publishing. cally the areas most structurally affected by disease: hippocampus, amygdala, pa- Other tissues of AD patients also can manifest rietal cortex, and other neocortical zones.20,21 oxidative stress. Van Rensburg et al found the blood of Oxidative stress is a relative increase in the ratio AD patients demonstrates increased oxidative stress of free radicals to antioxidants.21,22 Brain tissue is espe- and abnormally poor antioxidant status compared to cially vulnerable to oxidative attack due to its relatively healthy controls (Figure 2).22 low antioxidant capacity, high consumption of oxygen, high content of polyunsaturated fatty acids, and high content of redox-active transition metals such as iron.20 Page 90Copyright © 2008 Thorne Research, Inc. All Rights Reserved. No Reprint Without Written Permission. Alternative Medicine Review Volume 13, Number 2 June 2008
  7. 7. Alternative Medicine Review Volume 13, Number 2 2008 Review Article Reactive oxygen species (ROS) and reactive Butterfield’s group identified two mitochondri- nitrogen species (RNS), along with reactive aliphatic al proteins as oxidation-sensitive – ATP synthase and and aromatic carbon compounds (RCS) and many voltage-dependent anion channel protein (VDAC).20 other substances with free radical character, can react VDAC is essential for moving ATP out of the mito- with proteins, lipids, carbohydrates, DNA, and RNA, chondria. ATP synthase is pivotal to ATP production damaging or destroying cells.23 Alzheimer’s brain tissue as the end-stage of OXPHOS.30 Compromise to ATP displays ample amounts of damage to these molecular production capacity inside the mitochondria likely con- types.20,22 tributes to the energetic abnormalities of AD seen on Using a new technique of redox proteomics, PET imaging and to findings of altered glucose metabo- Butterfield et al are cataloguing specific oxidatively lism and tolerance in AD patients.20,31 damaged proteins in AD brain tissue.20 They identi- The Amyloid Cascade Hypothesis of Alzheim- fied 18 such damaged proteins involved in cholinergic er’s causation is based on the presence of extracellular and other neurotransmitter action, synaptic function amyloid deposition and to a lesser extent on intracell- and memory trace formation, cell structure, pH regula- ular NFT accumulation. It emphasizes amyloid-driven tion, and energetics. Seven are energy-related enzymes: inflammation as the primary initiating factor.32 Amyloid creatine kinase, alpha-enolase, lactate dehydrogenase may also stimulate oxidative stress, particularly since it (LDH), triosephosphate isomerase (TPI), phospho- has become clear that small, water-soluble amyloid oli- glycerate mutase I (PGMI), and glyceraldehyde-3- gomers permeate the brain.20,23,33 Of the two amyloid phosphate dehydrogenase (GAPDH). beta-peptides, AB42, the more toxic amyloid molecu- The presence of several glycolytic enzymes on lar species, has been found inside the mitochondria of this oxidative hit list (alpha-enolase, LDH, TPI, PGMI, AD neurons34 and is likely disruptive to mitochondrial and GAPDH) is especially significant because the brain function. is heavily dependent on glucose as its energy source. Gly- Considering that mitochondrial dysfunction colysis impairment would disrupt energetics through- reportedly enhances AB42 accumulation in the neuron out the AD brain. Butterfield’s group ascertained that cytoplasm, thereby enhancing neuronal vulnerability,35 beagle dogs are a good model of human AB42-induced these phenomena might contribute to a “vicious cycle” brain oxidation, and by feeding antioxidants to beagles involving amyloid deposition, mitochondrial failure, en- have succeeded in protecting some proteins from oxida- ergetic failure, functional neuronal impairment, and cell tive damage as their brains accumulate amyloid.24 death. Mitochondrial Compromise Early Energetic Decline Even worse than glycolytic compromise in the PET imaging can assess local cerebral glucose brain is compromise of oxygen-dependent energy gen- metabolism (lCGM) with increasing precision. Early eration – oxidative phosphorylation (OXPHOS), as PET studies have found neocortical higher-association occurs in the mitochondria.25,26 The mitochondria are areas in the AD brain demonstrated markedly decreased the energy-generating organelles of every human cell.25 glucose consumption, particularly the frontal and tem- Mitochondria are key players in oxidative stress phe- poral cortex.20,36,37 The primary visual and sensorimo- nomena because they generate more than 90 percent of tor cortex, basal ganglia, and cerebellum are relatively the cell’s endogenous oxidant species.26 Mitochondrial spared.36 Automated analysis of the lCGM neocortical degeneration has been suggested to contribute to Al- patterns from PET scans can distinguish between con- zheimer’s disease.27 Mitochondrial energetic enzymes trols and AD patients with 93-percent sensitivity and are markedly impaired in AD.28 Mitochondrial damage 93-percent specificity. Even very mild dementia (Mini- likely occurs early in AD; mitochondrial DNA shows Mental State Exam (MMSE) score 24 or higher) can be abnormally elevated oxidation products in the tempo- distinguished at 84-percent sensitivity and 93-percent ral, parietal, and frontal lobes of the AD brain.20,29 specificity.36 Page 91Copyright © 2008 Thorne Research, Inc. All Rights Reserved. No Reprint Without Written Permission. Alternative Medicine Review Volume 13, Number 2 June 2008
  8. 8. Alternative Medicine Review Volume 13, Number 2 2008 Alzheimer’s Disease The metabolic impairment seen with PET cor- cholinesterase inhibitor drugs involves blocking break- relates well with autopsy studies, which reveal decreased down of ACh, thus elevating ACh levels at the cholin- activity of pyruvate dehydrogenase (PDH) and the ergic synapses and (in theory) compensating for loss Krebs cycle enzyme alpha-ketoglutarate dehydrogenase of cholinergic circuits.41 However, in clinical trials and (KGD) in the frontal, temporal and parietal cortex.20 practice, cognitive benefits of CI drugs are minimal; Complex IV of the mitochondrial OXPHOS chain is more than half the subjects show no measurable im- also consistently decreased in the AD brain.38 provement. Furthermore, the window of efficacy aver- Evidence strongly suggests oxidative stress and mi- ages six months to one year; benefits fade as brain deter- tochondrial compromise both contribute to AD. Whether ioration worsens. these are primary initiating insults or whether one or both CI drugs seem to be well tolerated, with the arise secondary to previous insults is unclear. Findings that exception of tacrine. When prescribed by experienced brain tissue from MCI patients displays abnormally elevat- physicians under recommended guidelines, side effects ed protein damage suggest one or both dysfunctional states can include nausea, vomiting, loss of appetite, and in- could be primary contributors to AD.20,23 creased frequency of bowel movements. Combining CI drugs does not heighten efficacy and could increase ad- Current Medical Management of verse effects.2 Idebenone is a synthetic, low-molecular-weight Alzheimer’s Disease derivative of ubiquinone (coenzyme Q10). A 2002 RCT To treat cognitive symptoms, the U.S. Food and compared idebenone to tacrine in patients with mild-to- Drug Administration (FDA) has approved five drugs moderate probable AD.42 Patients (n=203) were ran- that affect the activities of two chemical neurotransmit- domized to either 360 mg idebenone (n=104) or 160 ter systems – acetylcholine and glutamate. mg tacrine (n=99) daily for 60 weeks. An Efficacy Index Score (EIS) integrated scores for cognitive function, ac- Cholinesterase Inhibitor Drugs tivities of daily living, and global function. The idebenone Acetylcholine is a neurotransmitter centrally patients showed higher EIS benefit than the tacrine pa- involved in learning, memory, judgment, attention, and tients. The significance of this trial is doubtful, however, concentration. Normally, ACh is transiently released at due to the poor compliance rate; after the 60-week treat- the presynaptic terminal, stimulates receptors on the ment period only 29 percent of idebenone patients and postsynaptic terminal, and is then rapidly broken down nine percent of tacrine patients were still on the drug. by the enzyme cholinesterase to terminate the synap- tic signal.25 Cholinesterase inhibitor (CI) drugs prevent the breakdown of ACh, thereby conserving ACh at the Glutamate Enhancement Glutamate is another prevalent brain neu- synaptic junctions. FDA-approved CI drugs are tacrine, rotransmitter. When released presynaptically, gluta- donepezil, galantamine, and rivastigmine.2 mate is essential to learning and memory via facilitation Tacrine was the first CI drug, approved in 1993 of n-methyl-d-aspartate (NMDA) receptors that allow (brand name Cognex®), but it is currently rarely pre- small influxes of calcium into stimulated nerve cells. scribed because of liver toxicity and other major adverse Limited increase of ionic calcium inside the cell triggers effects.39 Its immediate successor, approved for all stages changes required for long-term potentiation and the re- of AD, donepezil (Aricept®), is less toxic but still has lated processes that culminate in formation of a mem- appreciable adverse effects.40 Galantamine (Razadyne®) ory trace.25 Although the glutamate neurotransmit- and rivastigmine (Exelon®) are approved for mild-to- ter system is delicately balanced, excess glutamate can moderate AD.2 Donepezil appears to be the most effec- over-stimulate NMDA receptors, allowing too much tive and best tolerated, although all four CI drugs have calcium into the nerve cells, causing functional disrup- marginal clinical utility.2,39 tion and cell death. Pharmacological NMDA blockers Areas of the brain that depend predominantly down-regulate NMDA receptors and render them less on cholinergic circuitry are generally the first and most sensitive to overstimulation.2 severely damaged by AD.2 The mechanism involved in Page 92Copyright © 2008 Thorne Research, Inc. All Rights Reserved. No Reprint Without Written Permission. Alternative Medicine Review Volume 13, Number 2 June 2008
  9. 9. Alternative Medicine Review Volume 13, Number 2 2008 Review Article Memantine (Namenda®) is an NMDA-re- enzyme complex crucial for neuronal signal transduc- ceptor antagonist. Although memantine has shown no tion and memory trace formation.45 PKC dysfunction apparent benefits in mild-to-moderate AD, it is FDA is one of the earliest changes noted in AD and is being approved for moderate-to-severe AD.2 A 2007 meta- investigated as a target for drug development.46 analysis found limited but statistically significant ben- PS has been found effective for AD in six dou- efits for cognition, behavior, and activities of daily living ble-blind trials.45 At daily doses of 200-300 mg for up over a six-month trial period.43 Memantine’s side effects to six months, PS consistently improved clinical global include headache, constipation, confusion, and dizzi- impression and activities of daily living. In more mild ness. cases, PS improved orientation, concentration, learning, and memory for names, locations, and recent events. Nutrients for Alzheimer’s Disease: In the largest trial, involving 425 patients with moder- ate-to-severe cognitive loss, PS significantly improved Orthomolecules memory, learning, motivation, socialization, and general In 1968, two-time Nobel laureate, Linus Paul- “adaptability to the environment.”47 ing, PhD, conceived of the treatment of disease or the Animal experiments suggest PS has a trophic correction of metabolic imbalances by substances nat- (growth supportive) effect on the brain. Compared to urally part of human biochemistry – what he termed younger rats, older rats normally have fewer and smaller molecules orthodox to the body, orthomolecules.44 Pauling brain neurons and decreased cell surface-receptor den- predicted, because of intrinsic biochemical value and sity for nerve growth factor (NGF). These receptors evolutionary intimacy with living systems, orthomol- mediate the actions of NGF to enhance neuronal dif- ecules would be effective and safe for long-term use. ferentiation and other aspects of neuroplasticity. As This concept has been confirmed by the clinical rats age, they show declines in NGF-receptor density experience of nutritionally oriented physicians. Direct in the cerebellum, hippocampus, and other brain zones. validation at the biochemical level came with the report When dosed with PS, older rats retain more and larger by Ames et al in 2002,26 mostly from experiments with brain neurons along with higher NGF-receptor density. cultured cells, that at least 50 human genetic diseases In addition, when older rats are subjected to maze tests, involving defective enzymes could be remedied by in- a subpopulation that normally tests significantly more creasing available concentrations of a nutrient compo- impaired than the average are appropriately labeled “old nent of the coenzyme; the authors acknowledged Paul- impaired” rats in contrast to simply “old rats.” This im- ing’s contribution. paired subgroup shows the most improvement in cog- RCTs have demonstrated the efficacy of certain nition and NGF-receptor density when dosed with PS orthomolecules for AD; each is summarized in the sec- (Figure 3A).48 tion that follows. To ensure the scientific quality of the PS and most other phospholipids have fatty clinical research and for the sake of brevity, the review acids naturally incorporated in their “parent” molecular includes only double-blind trials. structure and position fatty acids in the membrane lipid bilayer.25 The more fluid the bilayer, the more efficient- Phosphatidylserine (PS) ly it functions. The most fluidizing fatty acids are the Phospholipids are molecular building blocks omega-3 fatty acids docosahexaenoic acid (DHA) and for cell membranes, the dynamic sites of most life pro- eicosapentaenoic acid (EPA). A marine-source omega-3 cesses.25 PS is a vital phospholipid found most con- PS containing DHA and EPA recently became avail- centrated in brain tissue. PS supports many cellular able as a dietary supplement. functions particularly important to the brain, including mitochondrial membrane integrity for energy produc- tion, neuronal membrane electrical depolarization, pre- synaptic neurotransmitter release, postsynaptic receptor activity, and activation of protein kinase C (PKC) – an Page 93Copyright © 2008 Thorne Research, Inc. All Rights Reserved. No Reprint Without Written Permission. Alternative Medicine Review Volume 13, Number 2 June 2008
  10. 10. Alternative Medicine Review Volume 13, Number 2 2008 Alzheimer’s Disease Figure 3A. Phosphatidylserine: One of Three Orthomolecules that Help Conserve NGF-Receptor Density in the Aging Rat Brain 4 % of Hippocampal Tissue Young Rats 3 with NGF Receptors Old Nonimpaired Old Impaired 2 Old Imp. + PS (p<0.05) 1 0 Cognitive Status Adapted from: Nunzi M, Guidolin D, Petrelli L, et al. In: Bazan NG, ed. Neurobiology of Essential Fatty Acids. New York: Plenum Press; 1992;393-398. Used with permission from Springer. Glycerophosphocholine (GPC, alpha-GPC, GPC at 1,200 mg/day for six months significantly ben- Choline Alphoscerate, Choline Alfoscerate) efited memory and other cognitive measures.52 A meta- Also a vital phospholipid orthomolecule, GPC analysis found GPC offered longer-lasting benefit for differs from PS in being water-soluble and is therefore Alzheimer’s disease compared with donepezil.53 located in the cytoplasm rather than within the cell GPC is also a neuroprotectant, as determined membrane. GPC attains high concentrations in some from a number of animal experiments. The nucleus tissues, protecting against osmotic shock and urea basalis of Meynert is a cholinergic zone that tends to at- buildup.49 rophy early in AD. In rats, oral GPC protected both the GPC is a cholinergic agonist and supports ACh NBM and its cholinergic projections to the forebrain homeostasis.50 Following oral dosing with GPC, brain cortex and hippocampus from chemically-induced tox- choline levels are markedly elevated within two hours.50 in damage.51,54 GPC raises blood choline with a sustained-release pat- Similar to PS, GPC helps conserve nerve tern, also elevating brain choline, a necessary precursor growth factor receptors in aging rats (Figure 3B).55 Oral for biosynthesis of ACh. Besides typically being the first GPC protected against this decline in the hippocam- chemical transmitter to become dysfunctional in AD, pus, a brain zone highly dependent on NGF and most ACh is ubiquitously distributed throughout the body active in producing new neurons from stem cells.56 and not limited to neurons.41 GPC demonstrates benefit in AD patients for orientation, attention, memory, language, and mood.51 In a large, double-blind RCT involving 261 patients, Page 94Copyright © 2008 Thorne Research, Inc. All Rights Reserved. No Reprint Without Written Permission. Alternative Medicine Review Volume 13, Number 2 June 2008
  11. 11. Alternative Medicine Review Volume 13, Number 2 2008 Review Article Figure 3B. Glycerophosphocholine: One of Three Orthomolecules that Help Conserve NGF-Receptor Density in the Aging Rat Brain 100 % Cerebellar Purkinje Cells 80 Adult Rats Binding Radio-NGF Old Rats 60 Old Rats + GPC 40 20 0 Cognitive Status Adapted from: Vega JA, Cavallotti C, Del Valle ME, et al. Nerve growth factor receptor immunoreactivity in the cerebellar cortex of aged rats: effect of choline alfoscerate treatment. Mech Ageing Dev 1993;69:119-127. Used with permission from Elsevier. Acetyl-L-Carnitine (ALC) Omega-3 Fatty Acids ALC, the acetyl ester of the amino acid carni- Epidemiological studies indicate rela- tine, is important for energetics in the brain and other tis- tively high intakes of DHA and EPA are sues. ALC transports fatty acids from the cell cytoplasm linked to lower risk of dementia incidence or progres- into the mitochondria where they provide substrate for sion, and that better DHA and EPA status correlates ATP generation via oxidative phosphorylation. ALC, with slower cognitive decline over time. The 1997 Rot- subjected to numerous double-blind trials for AD, has terdam Study, tracking 5,386 participants age 55 or shown limited but measurable effectiveness. older for an average of 2.1 years, found a significant link In a 2003 meta-analysis by Montgomery et al between high fish consumption and lowered Alzheim- that examined double-blind, placebo-controlled trials of er’s disease risk (RR=0.3; 95% CI=0.1-0.9).59 A com- at least three-month duration, ALC showed significant munity study in Chicago followed 815 residents ages benefit over placebo.57 Daily intakes of ALC of 1.5-3.0 g 65-94 for an average 3.9 years and found consumption were well tolerated. of one fish meal weekly can decrease the risk of AD by As with PS and GPC, ALC conserves NGF- 60 percent compared to individuals who rarely or never receptor density in the aging rat brain, partially restor- eat fish (RR=0.4; 95% CI=0.2-0.9).60 Total omega-3 ing a youthful receptor profile (Figure 3C).58 intake and DHA intake, but not EPA intake alone, were significantly associated with decreased AD risk. Page 95Copyright © 2008 Thorne Research, Inc. All Rights Reserved. No Reprint Without Written Permission. Alternative Medicine Review Volume 13, Number 2 June 2008
  12. 12. Alternative Medicine Review Volume 13, Number 2 2008 Alzheimer’s Disease Figure 3C. Acetyl-L-Carnitine: One of Three Orthomolecules that Help Conserve NGF-Receptor Density in the Aging Rat Brain 100 Hippocampal Radio-NGF Binding (femtomoles per mg tissue) 80 Young Rats Old Rats 60 Old Rats + ALC 40 20 0 Cognitive Status Adapted from: Angelucci L, Ramacci MT, Taglialatela G, et al. Nerve growth factor binding in aged rat central nervous system: effect of acetyl-L-carnitine. J Neurosci Res 1988;20:491-496. Used with permission from Wiley-Liss, Inc. Epidemiological studies can be more reliable which all received the DHA/EPA supplements for six when tissue biomarkers are available. One such study more months. No significant difference was found for at Tufts University measured DHA in plasma phos- the large-group comparisons, but in a subgroup with pholipids, specifically as DHA incorporated into phos- less severe cognitive dysfunction (MMSE score >27 phatidylcholine (PC-DHA). A cohort of 1,188 elderly points), receiving DHA and EPA was associated with Americans (average age 75) was analyzed at baseline a significantly slower decline. and 10 years later.61 Individuals in the lower half of In 2007 this group reported specifically on the DHA levels at baseline had a 67-percent greater risk of neuropsychiatric outcomes of the above Alzheimer’s developing AD within the subsequent 10-year period trial.65 The researchers noted significant improvement compared to those with DHA levels in the upper half of agitation in ApoE4 carriers, and improvement of de- (p<0.05). The correlation of low plasma DHA with AD pression in non-ApoE4 carriers. was confirmed in a Canadian study.62 An Irish group Many clinical studies suggest higher intake of analyzed serum cholesteryl-DHA and -EPA esters and DHA and EPA protects against AD risk factors cardio- found both abnormally low in AD subjects.63 vascular dysfunction, insulin resistance, and systemic Only one double-blind, prospective RCT of inflammation.59,66,67 The extensive clinical research on omega-3 DHA and EPA for treatment of AD has been omega-3 benefits for the brain was recently reviewed in published.64 Patients (n=174) received either 1.7 g DHA this journal.67 and 0.6 g EPA daily or a placebo for six months, after Page 96Copyright © 2008 Thorne Research, Inc. All Rights Reserved. No Reprint Without Written Permission. Alternative Medicine Review Volume 13, Number 2 June 2008
  13. 13. Alternative Medicine Review Volume 13, Number 2 2008 Review Article Cold-water fish are the best dietary sources of seven months and was slightly more beneficial than DHA and EPA. Land-based foods providing shorter- selegiline. chain omega-3s are less useful because enzymatic con- Following on the enthusiastic response to suc- version to long-chain DHA and EPA is limited, even in cess in this trial, the ADCS organized another, larger healthy people.67 However, great care must be exercised double-blind RCT of vitamin E.70 Subjects (n=769) in sourcing fish because of the risks of contamination with amnestic mild cognitive impairment were random- by heavy metals and organic pollutants. The expand- ized to either 2,000 IU vitamin E, 10 mg donepezil, or ing availability of DHA and EPA in supplements, eggs, placebo for three years. Vitamin E failed to show ben- beverages, and other staple foodstuffs now makes it efit. possible to ingest the recommended amounts for ad- The form of vitamin E used for these two tri- equate nutritional status (in excess of 1 g per day total als was DL-alpha-tocopherol, the racemic commercial DHA+EPA). isomer of one of the four tocopherols that have vitamin E activity. Vitamin E is actually a combination of several Omega-6 Essential Fatty Acids tocopherols. Recent findings suggest alpha-tocopherol Horrobin et al analyzed red blood cells (RBCs) may not be the most representative vitamin E for hu- from 36 AD patients for omega-3 and -6 essential fatty mans because our foods actually contain more gamma- acids and found both were abnormally low.68 Interest- tocopherol,71 which demonstrates greater anti-inflam- ingly, the omega-3 levels were within normal range in matory activity than alpha-tocopherol.72 The Chicago plasma, but only 60-70 percent of normal in RBCs. Health and Aging Project found increased vitamin E All 36 patients entered a double-blind, ran- intake (from the diet but not from supplements) corre- domized, placebo-controlled trial. One patient group lated with lowered AD risk.73 Future trials with vitamin received evening primrose oil (EPO) containing linoleic E might more appropriately include a mixed-tocopherol acid (18:2, omega-6) and gamma-linolenic acid (18:3, supplement. omega-6); the exact daily intakes were not provided. To Increasing evidence suggests nutrients regulate protect against oxidation, the EPO group also received gene activity. New gene chip technology demonstrates antioxidants vitamin E, selenium, and zinc (intakes un- vitamin E deficiency can have a strong impact on gene specified). The placebo group received identical-appear- expression in the hippocampus, a key area afflicted by ing capsules with antioxidants only. After 20 weeks, the AD. Rota et al used Affymetrix gene chip technology, EPO group showed significant improvement on six of capable of recording as many as 7,000 genes on a single eight cognitive tests; the placebo group significantly im- chip.74 Rats were fed a diet lacking in vitamin E for nine proved on three of eight tests. The EPO group showed months. The hippocampus was removed and the genes significant improvements in the Hamilton Depression extracted, then hybridized onto the gene chip (one chip Rating, the Colored Progressive Matrices Test, and the per animal). Vitamin E deficiency was found to down- Graded Naming Test compared to the placebo group. regulate 948 genes; among which were genes for growth hormone, thyroid hormones, insulin-like growth fac- tor I, NGF, melatonin, dopaminergic neurotransmis- Vitamin E sion, and clearance of advanced glycation end products When the first double-blind RCT of vitamin (AGEs). In particular, vitamin E deficiency strongly E for AD was published in the New England Journal of down-regulated genes coding for proteins related to Medicine it caused a sensation. This trial was conducted clearance of beta-amyloid. by the Alzheimer’s Disease Cooperative Study (ADCS; In vivo, vitamin E operates with endogenous a consortium of North American AD researchers) at antioxidant enzymes and other nutrient antioxidants several prestigious American academic centers. A total against oxidative challenge.75 For example, vitamin E of 341 patients with moderate AD were randomized in lipid cell membranes complements vitamin C in the to placebo, selegiline, vitamin E, or vitamin E plus sele- cytoplasm and other water phases. Alzheimer’s patients giline for two years.69 Vitamin E at a high daily intake tend to have low serum levels of vitamins E and C, but (2,000 IU) was found to delay disease progression by Page 97Copyright © 2008 Thorne Research, Inc. All Rights Reserved. No Reprint Without Written Permission. Alternative Medicine Review Volume 13, Number 2 June 2008
  14. 14. Alternative Medicine Review Volume 13, Number 2 2008 Alzheimer’s Disease Figure 4. The Nun Study: Degrees of Atrophy of the Neocortex, Plotted against Baseline Blood Folate Levels No Atrophy Mild Atrophy Moderate Atrophy Severe Atrophy 0 20 40 60 80 100 120 140 160 180 200 Serum Folate (nmol/L) From: Snowdon DA, Tully CL, Smith CD, et al. Serum folate and the severity of atrophy of the neocortex in Alzheimer disease: findings from the Nun Study. Am J Clin Nutr 2000;71:993-998. this could be related to poor eating habits associated Citicoline with the disease.76 Prospective epidemiological studies Citicoline (cytidine diphosphate choline, cyti- are more reliable assessments of relationships between dine diphosphocholine, CDP-choline) is an energy-ac- vitamin deficiencies and AD. In the Rotterdam Study, tivated form of choline – choline linked to cytidine by a individuals who reported higher intakes of vitamins diphosphate bridge. It is an intermediate in the biosyn- C and E at baseline had lower incidence of AD.77 The thesis of phosphatidylcholine.53 Cache County Study found an association between Citicoline has been tested for Alzheimer’s dis- incidence of AD and intake of both vitamins C and ease in two double-blind, placebo-controlled trials. The E as dietary supplements, but not with either vitamin first involved 30 patients with mild-to-moderate AD alone.78 treated with 1,000 mg oral citicoline daily for three The National Institute on Aging is currently months.79 Although the overall results showed differ- recruiting for a trial on vitamin E plus selenium for AD. ences between the citicoline and placebo groups, these In this trial (as has been the case in previous studies), did not reach statistical significance. vitamin E is being provided only as alpha-tocopherol, The second double-blind trial compared citico- although abundant evidence favors also including gam- line with posatirelin (L-pyro-2-aminoadipyl-L-leucil- ma-tocopherol. Based on previous research, a better L-prolinamide, a synthetic tripeptide) or vitamin C (all study design would have included vitamin C, selenium, administered intramuscularly once daily) in 222 AD and possibly other antioxidant nutrients with vitamin outpatients for three months.80 Posatirelin was superior E. Combination therapy (several nutrients or nutrients to citicoline and ascorbic acid on the Gottfries-Brane- plus conventional medications) may offer greater po- Steen (GBS) dementia rating scale. Posatirelin scored tential to slow or substantially improve quality of life significantly superior to both on intellectual impair- in AD. ment, impaired orientation and memory, impaired at- tention and motivation, activities of daily living, and motor impairment. Page 98Copyright © 2008 Thorne Research, Inc. All Rights Reserved. No Reprint Without Written Permission. Alternative Medicine Review Volume 13, Number 2 June 2008
  15. 15. Alternative Medicine Review Volume 13, Number 2 2008 Review Article A 2005 meta-analysis by the Cochrane group Thiamine assessed citicoline for the treatment of cognitive, emo- Thiamine (vitamin B1) is important for glucose tional, and behavioral deficits associated with chronic metabolism, which is known to decline early in AD; its cerebral disorders in the elderly.81 The reviewers con- deficiency can cause irreversible cognitive impairment. cluded there was some benefit on memory function and Thiamine was used at high doses (3-8 g daily) in three behavior. They suggested future clinical trials should double-blind trials that altogether included fewer than extend longer and focus on vascular-related cognitive 50 subjects.88,89 The reported outcomes were inconclu- impairment. sive, partly due to poor disclosure of trial details. Folic Acid Botanicals for Alzheimer’s Disease Although the essentiality of folic acid for neu- Ginkgo Biloba Extracts (GBE) ral tube formation in the developing fetus is well estab- Standardized leaf extracts of Ginkgo biloba lished, the Nun Study illuminated folate’s pivotal im- (GBE) are the most exhaustively tested botanicals for portance in the adult brain.15,82 AD and other dementias. Ginkgo is usually standard- Snowdon et al found a strong association be- ized to contain 24-percent flavone glycosides and six- tween low blood folate and severity of atrophy in the percent terpene lactones (24/6) by weight. neocortex on routine blood samples (Figure 4). GBE trials specifically for AD are limited. A 1998 meta-analysis by Oken and Storzbach identified Vitamin B12 four randomized, double-blind, placebo-controlled Vitamin B12 deficiency is common in AD pa- trials, which totaled 212 subjects given GBE and 212 tients. Miller reviewed correlation between B12 defi- given placebo. Overall the meta-analysis found a small ciency and increased AD.83 B12 deficiency often occurs but statistically significant effect – a three-percent im- concurrently with folate deficiency. In a longitudinal provement on the Alzheimer’s Disease Assessment study that followed 370 non-demented subjects for Scale-Cognitive subscale (ADAS-Cog).90 three years, individuals with poor vitamin B12 and folate In 2002, LeBars et al reported a re-analysis status had double the risk for developing AD.84 of the AD patients from an earlier double-blind RCT A double-blind RCT was conducted in Taiwan that included other dementias.91 In this trial 120 mg with 89 mild-to-moderate AD patients.85 The patients EGb 761, a 24/6 preparation, was used daily for one were prescribed a CI drug, then were randomized to re- year. For AD patients least severely afflicted at baseline ceive either a placebo or a B12-multivitamin supplement (>23 MMSE), significant improvements were seen (500 mcg methylcobalamin, 1,000 mcg folic acid, 5 mg over placebo on the ADAS-Cog scale (1.7 points) and vitamin B6, other vitamins and iron (amounts unspeci- on the caregiver’s Geriatric Evaluation by Relative’s fied)) for 26 weeks. No statistically significant differ- Rating Instrument (GERRI) scale (0.09 points). For ences were found between groups, either in cognition or those patients moderately afflicted (MMSE <24), the activities of daily living, although blood homocysteine ADAS-Cog improved by 2.5 points and the GERRI (HCy) levels were significantly reduced in the test group did not significantly improve. For patients most severely compared to the placebo group. afflicted at baseline (MMSE <15), those taking EGb Vitamins B6 and B12 and folate are cofactors for 761 deteriorated significantly less than placebo on the enzymes that recycle or otherwise deplete HCy.83 The ADAS-Cog and GERRI scales. LeBars’ group conclu- Mediterranean diet, which is relatively high in these nu- ded EGb 761 improved AD patients with mild or mod- trients, has been linked to lowered incidence of AD.86 erate cognitive impairment and stabilized or slowed the Elderly individuals who followed the Mediterranean decline of those most severely afflicted. diet were found to have a 40-percent lower AD risk.86 The Mediterranean diet also may lower mortality in pa- tients with established AD.87 Page 99Copyright © 2008 Thorne Research, Inc. All Rights Reserved. No Reprint Without Written Permission. Alternative Medicine Review Volume 13, Number 2 June 2008
  16. 16. Alternative Medicine Review Volume 13, Number 2 2008 Alzheimer’s Disease In 2003, LeBars published another analysis of GBE’s efficacy and safety for AD prevention is the data, this time subgrouping AD patients according being examined in the large GuidAge Study – a French to neuropsychological profiles.92 Patients with “right multicenter, double-blind, randomized trial in prog- AD” (primarily visual-constructional impairment) may ress.100 A total of 2,854 subjects with memory com- have benefited more from EGb 761 than those with plaints were enrolled and randomized to receive either “left AD” (primarily verbal deficits). In the “right AD” 240 mg EGb 761 or a placebo daily for five years. Final group improvements on ADAS-Cog and GERRI were results should be available in 2010. minimal. In a 2007 Ukrainian double-blind RCT, EGb Vinpocetine 761 for 22 weeks significantly improved neuropsychi- Vinpocetine is an alkaloid extracted from the atric symptoms and activities of daily living in mild or plant Vinca minor (lesser periwinkle). Vinpocetine is a moderate stage AD patients.93 vasodilator and cerebral metabolic enhancer that has GBE dosages in RCTs for AD ranged from shown promise for vascular cognitive impairment. In a 120-240 mg daily for 3-12 months.90-94 The relatively 1989 open-label, dose-ranging trial conducted for one limited brain efficacy of GBE preparations may be re- year with 15 Alzheimer’s patients at the University of lated to poor bioavailability. A proprietary preparation California, San Diego, doses of vinpocetine up to 60 of GBE combined with phosphatidylcholine has dem- mg/day failed to show benefit for cognition or Clinical onstrated superior bioavailability over GBE alone.95 Global Impression.101 Although standardized Ginkgo biloba extracts have demonstrated few adverse effects, two case reports Huperzine linking GBE to brain micro-hemorrhages constitute Huperzine is an alkaloid extracted from the cause for concern.96 In a 2006 RCT, 50 healthy male plant Huperzia serrata (Chinese club moss). In a dou- subjects received either 500 mg acetylsalicyclic acid ble-blind RCT on AD conducted in China in 1995, (ASA; aspirin) or 500 mg ASA plus 240 mg EGb 761 400 mcg oral huperzine daily for 56 days was reported daily for seven days.97 Bleeding time was prolonged by to significantly improve memory, other cognition, and ASA as expected, but ASA plus EGB 761 did not fur- behavioral functions compared to placebo.102 Yet a sub- ther prolong bleeding time. Platelet aggregation was sequent double-blind RCT published in 1999 by the inhibited almost identically by ASA and by ASA plus same group reportedly found the same dose of huperzine EGb 761. The researchers concluded safety of EGb 761 taken for the same period failed to perform significantly was demonstrated in this trial. better than placebo.103 Since that time no new data from In a U.S. RCT, 78 healthy older adults (ages RCTs has appeared on huperzine for Alzheimer’s dis- 65-84) received a mixed dietary supplement providing ease. A U.S. trial is underway as of 2008.104 160 mg GBE, 68 mg gotu kola, and 180 mg DHA daily for four months. Platelet function testing demonstrated no adverse effect from the supplement.98 Other Botanicals GBE has also been directly compared to a Many other botanicals have potential for AD cholinesterase inhibitor – donepezil. In a double-blind treatment. Polyphenols have in common potent anti- RCT, 60 patients with mild-to-moderate AD were ran- oxidant and anti-inflammatory activity. Those currently domized to either EGb 761 (160 mg/day), donepezil showing the most promise for cognitive support are cur- (5 mg/day), or placebo.99 According to Clinical Global cumin from turmeric, green tea catechins, blueberry fla- Impression, both the Ginkgo and donepezil groups vonoids (especially the diverse assortment from lowland demonstrated comparable mild improvement. Both also blueberries), and resveratrol and associated flavonoids had comparable dropout rates (20 percent for EGb 761 from grapes, wine, berries, and peanuts.105 Other phyto- and 16 percent for donepezil). The investigators sug- nutrients under investigation include sage essential oil, gested given the comparable efficacy and safety of the rosmarinic acid from rosemary, and cholinergic prin- two agents, GBE could reasonably be substituted for ciples from lemon balm.106 the more expensive donepezil. Page 100Copyright © 2008 Thorne Research, Inc. All Rights Reserved. No Reprint Without Written Permission. Alternative Medicine Review Volume 13, Number 2 June 2008

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