Timo Grimmer

Background: The viral hypothesis of Alzheimer’s disease (AD) proposes that neurotropic pathogens may interact with amyloid and tau pathology, but the evidence remains controversial. We investigated whether cerebrospinal fluid (CSF) kallikrein-related peptidase 6 (KLK6) is associated with AD biomarkers and with an intrathecal anti-HSV immune response in patients with AD, and whether HSV-1 infection alters KLK6 expression in cell culture models. Methods: CSF KLKs and AD biomarkers were analyzed in patients with AD. HSV-1 serostatus and anti-HSV-1/2 CSF-to-serum antibody index (HSV-AI) were used as markers of previous or ongoing intrathecal anti-HSV immune response. In vitro, HSV-1 infection and KLK6 knockdown were examined in human cell models. Results: CSF-KLK6 correlated with tau and amyloid biomarkers. In HSV-1-seropositive patients, HSV-AI was associated with CSF-KLK6, although the effect size was modest and the association was strongly context-dependent on the Aβ42/40 ratio. In vitro, productive HSV-1 infection induced and stabilized KLK6 protein expression, and KLK6 knockdown reduced HSV-1 protein expression and infectious progeny in HaCaT cells. Conclusions: KLK6 is associated with AD biomarkers and with an intrathecal anti-HSV immune response in a subset of patients with AD. The in vitro data support a functional relationship between HSV-1 infection and KLK6, but the clinical findings are associative and do not demonstrate ongoing CNS HSV-1 replication or causality. These findings warrant independent validation. However, this research provides further evidence for a role of HSV-1 in the pathophysiology of AD.

Background: The increasing global prevalence of dementia, where early intervention can significantly impact treatment outcomes and costs, necessitates effective early diagnostic tools, particularly in primary care settings. This study evaluates the Bayer Activities of Daily Living (Bayer‐ADL) scale as a potential screening tool to distinguish between Mild Cognitive Impairment (MCI) and dementia. Method: Conducted at the Center for Cognitive Disorders, Technical University of Munich, the study analyzed data from 503 patients who also had a comprehensive diagnostic work‐up including a standardized assessment of the presence and severity of dementia, using the Clinical Dementia Rating scale (CDR) and a thorough neuropsychological examination using the Consortium‐to‐Establish‐a‐Registry‐in‐Alzheimer’ Disease neuropsychological assessment battery (CERAD‐NAB) using bivariate correlations, linear regression, and ROC curves. To select key questions of the ADL scale a stepwise variable selection process was applied. Result: The findings demonstrate that three key questions of the Bayer‐ADL scale effectively differentiate MCI from dementia with high predictive accuracy (AUC = 0.836). The 3‐tem short version offers comparable predictive power to the full scale (37% each), suggesting its utility in primary care for streamlined dementia assessment. Conclusion: Consideration should be given to offering the 3‐item short version of the questionnaire to improve the efficiency and accuracy of dementia screening in primary care settings.

INTRODUCTION: Amyloid beta 1–42 (Aβ42), tau phosphorylated at threonine‐181 (p‐tau181), and total tau (t‐tau) are cerebrospinal fluid (CSF) biomarkers for Alzheimer's disease diagnosis. METHODS: We prospectively examined storage time, temperature, and freeze/thaw effects on Aβ42, p‐tau181, and t‐tau stability in fresh CSF samples using Elecsys ^® CSF immunoassays. RESULTS: All three biomarkers were stable at 2–8°C for ≤15 days, and −25°C to −15°C for ≤8 weeks, and after one freeze/thaw cycle. p‐Tau181 and t‐tau were also stable at 15–25°C for ≤8 days and at −25°C to −15°C for 12–15 weeks. Aβ42 recovery declined slightly after storage at 15–25°C for ≤8 days and −25°C to −15°C for 12–15 weeks, and one freeze/thaw cycle. DISCUSSION: For optimal immunoassay performance, it is recommended to store CSF samples at 15–25°C for ≤5 days, 2–8°C for ≤15 days, and −25°C to −15°C for ≤8 weeks. Highlights: Cerebrospinal fluid (CSF) biomarkers aid in Alzheimer's disease diagnosis. Fresh CSF stored at 15–25°C for ≤5 days is optimal for Elecsys CSF immunoassays. Fresh CSF stored at 2–8°C for ≤15 days is optimal for Elecsys CSF immunoassays. Fresh CSF stored at −25°C to −15°C for ≤8 weeks is optimal for Elecsys CSF immunoassays.

IMPORTANCE There are no approved oral disease-modifying treatments for Alzheimer’s disease (AD) with the ability to prolong time in a stable disease state and with clinically meaningful outcomes clear to patients and caregivers. DESIGN The Phase IIb/III ANAVEX2-73-AD-004 study was a randomized, double-blind, placebo-controlled, 48-week trial with prespecified gene or GWAS identified genetic variant populations related to the mechanism of the pharmacological intervention. OBJECTIVE Providing evidence of improved Precision Medicine neurology clinical treatment responses with optimal blarcamesine dose for up to ∼70% of AD patients within prespecified SIGMAR1 (ABCLEAR1) and GWAS identified COL24A1 (ABCLEAR2) and SIGMAR1/COL24A1 (ABCLEAR3) non-missense gene populations. Describing once-daily, oral therapeutic intervention of blarcamesine in early AD, with a differentiated upstream and constitutional mechanism of action by enhancing autophagy through SIGMAR1 activation and restoration of cellular homeostasis. SETTING Multicenter - 52 medical research centers/hospitals in 5 countries. INTERVENTION 508 participants with Early AD (Stage 3) were randomized to receive blarcamesine (n = 338) oral capsules once daily either in medium dose group (30 mg) or in high dose group (50 mg) or placebo (n = 170) for 48 weeks. An open-label-extension study ATTENTION-AD, continued for up to 192 weeks. MAIN OUTCOME AND MEASURES Further improved clinical and biomarker outcomes of the ABCLEAR2 and ABCLEAR3 populations were accretive to the previously reported intent-to-treat (ITT) and prespecified ABCLEAR1 populations. The co-primary cognitive and functional outcomes were assessed as changes in ADAS-Cog13 and ADCS-ADL from baseline to 48 weeks. The outcomes include the secondary outcome CDR-SB as well as patient assessed clinical outcomes CGI-I, NPI-Q and QoL-AD (Quality of Life AD Patient) as well as biomarkers global brain volume changes measured by MRI. All clinical endpoints were analyzed using mixed model for repeated measures (MMRM), and volumetric MRI scans were analyzed by general linear model. RESULTS The ITT population (mean age, 73.7 years; 225 [48.7%] women), consisted of 462 randomized participants, with ABCLEAR1 population comprising of 300 participants, ABCLEAR2 population of 336 participants and ABCLEAR3 of 222 participants. In both the ABCLEAR2 and ABCLEAR3 populations, the co-primary outcomes as well as all other clinical outcomes were statistically significant. ABCLEAR3 blarcamesine group vs. placebo at Week 48 (ADAS-Cog13 difference of −4.179 [95% CI −6.512, −1.845]; P=0.0005; ADCS-ADL difference of +3.131 [95%CI 0.720, 5.542]; P=0.0111; CDR-SB difference of −1.076 [95% CI −1.645, −0.508]; P=0.0002; QoL-AD Patient improvement from baseline of 0.334 [95% CI −1.164, 1.833] and difference of 1.848 [95% CI 0.455, 3.241]; P=0.0095). The clinical outcomes were strongest in the blarcamesine 30 mg cohort (ADAS-Cog13 difference of −4.739 [95% CI −7.370, −2.108]; P=0.0004; ADCS-ADL difference of +4.245 [95%CI 1.518, 6.972]; P=0.0024; CDR-SB difference of −1.414 [95% CI −2.054, −0.775]; PCONCLUSIONS AND RELEVANCE Blarcamesine group demonstrated a balanced safety profile with no associated neuroimaging adverse events. The respective once-daily oral 30 mg blarcamesine cohort in the respective ABCLEAR1, ABCLEAR2, and ABCLEAR3 populations demonstrates further improvement of the already adequate safety profile of the ITT population and hence representing the dose with the most balanced benefit-to-risk ratio. In both ABCLEAR2 and ABCLEAR3 populations significant slowing in decline and even stabilization of clinical worsening was demonstrated. Blarcamesine group vs. placebo was 75.9% reduction in decline at 48 weeks in the total blarcamesine group and was 84.7% in the 30 mg dose group, respectively on the prespecified co-primary cognitive endpoint ADAS-Cog13 in the ABCLEAR3 population. Blarcamesine demonstrated consistently significantly improved clinical effect for all clinical endpoints, which was in accordance with significant and further reduced brain atrophy. Furthermore, a significant absolute improvement in Quality of Life (QoL-AD) scores indicating a reversal of negative trajectory for Alzheimer’s disease patients from baseline to end of trial was observed. The Phase IIb/III ANAVEX2-73-AD-004 clinical study confirmed blarcamesine’s consistent efficacy leading to improved cognitive stabilization with continued benefit in the open-label-extension study ATTENTION-AD up to 192 weeks. Evidenced by the Precision Medicine paradigm, including in a prespecified ABCLEAR1 population, a consistent significant improvement for all clinical endpoints in the ABCLEAR2 and ABCLEAR3 populations, respectively, was demonstrated. Coupled with a convenient once daily, oral pill administration, blarcamesine could represent a novel treatment option for up to ∼70% of early AD patients benefiting from further improved outcomes using directed Precision Medicine to alleviate significant medical and economic burden. TRIAL REGISTRATION Clinicaltrials.gov: NCT03790709; Open-label extension NCT04314934 FUNDING This work was funded by Anavex Life Sciences. Key Message Within a heterogeneous Alzheimer’s disease (AD) population, clinical utility of disease-modifying drug candidates could be enhanced via a Precision Medicine approach of treating those with target-relevant genetic profiles, excluding missense gene populations. This effective targeting could alleviate significant medical and economic burden.

The behavioral variant of frontotemporal dementia (bvFTD) is related to a variety of social misbehaviors, including criminal behavior (CB) due to deep changes in cognition, behavior, and personality. Recent work suggests that impairment in emotional processing, along with disinhibition, constitutes the necessary elements for CB in bvFTD. However, the underlying neurobiological mechanisms are still unclear. Therefore, we aim at investigating structural and functional brain changes related to CB in bvFTD using magnetic resonance imaging (MRI) with the German Consortium for Frontotemporal Lobar Degeneration (FTLD). Our study comprised 87 patients with bvFTD and 26 healthy controls recruited within different locations of the FTLD Consortium. A subset of 21 patients with bvFTD showed CB, including theft, physical violence, sexual assault, drug abuse, and violations against traffic law. Voxel‐based morphometry was performed, generating gray matter density (GMD) images obtained from high‐resolution T1‐weighted MR images. In addition, surface‐based morphometry was performed by reconstruction of cortical thickness using a projection‐based thickness approach. Both GMD and cortical thickness were further analyzed in order to detect group differences between bvFTD with and without CB. Resting‐state functional MRI was available for a subgroup of 56 patients with bvFTD, including 16 patients showing CB. On a behavioral level, CB in bvFTD was associated with a higher frequency of disinhibition, lower frequency of apathy, and better performance in verbal fluency. Comparing bvFTD with and without CB, we obtained reduced GMD and reduced cortical thickness in the temporal lobe, predominantly in the left hemisphere. Impairment in brain structure was correlated with the Frontal Systems Behavior Scale, particularly with disinhibition, in the left superior temporal gyrus in interaction with CB in bvFTD. Investigating functional MRI data, CB was associated with significant functional brain dysconnectivity, particularly between the left anterior superior temporal gyrus and widely distributed cortical regions, including areas in the vicinity of the precentral sulcus and the inferior frontal junction, related to executive functions. Our study revealed structural and functional brain differences between bvFTD with and without CB, showing CB‐related reduced GMD and cortical thickness in the left temporal lobe, indicating disinhibition as the main driver for CB. Interestingly, brain degeneration in the temporal lobe is discussed with CB in bvFTD in the current literature, dominantly affecting the right hemisphere. Our study investigates specifically the neural correlates of CB in bvFTD with MRI, modifying this view. Further work is necessary to shed more light on the role of the temporal lobe in bvFTD with CB.

The increasing number of people living with dementia and its burden on families and systems particularly in low‐ andmiddle‐income countries require comprehensive and ecient post‐diagnostic management. This study aimed to explore the acceptability and ecacy of a multi‐professional case management and psychoeducation model (North Macedonia Interprofessional Dementia Care, or NOMAD) delivered bymobile teams for people with dementia and their caregivers in North Macedonia. We conducted a two‐arm randomized controlled trial comparing the intervention with treatment as usual. Participants were recruited from 12 general practitioner (GP) oces in the Skopje region. The NOMAD intervention included the delivery of a personalized care plan over four home visits to dyads of people with dementia and their caregivers by a team including a dementia nurse and a social worker, in collaboration with GPs and dementia experts, and the introduction of a caregiver manual. We assessed caregivers’ depressive symptoms, burden, and quality of life and the neuropsychiatric symptoms, daily living activities, and service utilization of people with dementia at baseline and follow‐up; we also assessed the acceptability of the intervention by analyzing case notes and attendance rates. One hundred and twenty dyads were recruited and randomized to either the control (n = 60) or the intervention group (n = 60). At follow‐up, caregivers in the intervention group had, on average, scores that were 2.69 lower for depressive symptoms (p = 0.012), and people with dementia had, on average, 11.32 fewer neuropsychiatric symptoms (p = 0.009) and used, on average, 1.81 fewer healthcare services (p < 0.001) compared to the control group. The completion of the home visits was 100%, but the intervention’s acceptability was underpinned by relationship building, GP competencies, and resources to support families with dementia. NOMAD is the first casemanagement, non‐pharmacological, and multi‐professional intervention tested in North Macedonia. The trial showed that it is effective in reducing caregivers’ depressive symptoms and neuropsychiatric symptoms in people with dementia and the burden on health and social care services, and it is acceptable for families. Implementing NOMAD in practice will require building primary care capacity and recognizing dementia as a national priority.

Background: Biomarkers in cerebrospinal fluid (CSF) can help to diagnose Alzheimer’s disease (AD) and classify patients according to the amyloid/tau/neurodegeneration (ATN) research framework.Method: We directly compared the performance of three different testing systems, i..e. traditional solid‐phase sandwich ELISA assays (Innotest®, Fujirebio Europe N.V., Gent, Belgium, and IBL, Minneapolis, USA), a fully automated electrochemiluminescence immunoassays (ECLIA) platform (Elecsys® CSF assays measured on the cobas e 411 analyzer, Roche Diagnostics International Ltd, Rotkreuz, Switzerland), and a fully automated chemiluminescent enzyme immunoassays (CLEIA) platform (Lumipulse® G600II, Fujirebio Europe N.V., Gent, Belgium), in 50 early AD patients (64±8.1y) and 25 cognitively unimpaired (CU) controls (65±9.4y)] from the same cohort. Individual CSF biomarkers Aβ42, Aβ40, pTau181 and tTau were measured using all systems. Ratios for pTau181/Aβ42, tTau/Aβ42, Aβ42/Aβ40, pTau181/Aβ42/Aβ40, tTau/Aβ42/Aβ40, pTau181/Aβ40, and tTau/Aβ40 were calculated.Result: Across all systems, biomarkers and their ratios accurately distinguished AD patients from CU in a comparable manner: ROC: AUCs >0.96 (upper bound of CI:1.0)], except for ELISA Aβ42/Aβ40 [AUC = 0.948 (CI: 0.901‐0.995)]; according to Youden Index (YI)‐derived optimal cut‐offs, sensitivity and specificity were comparably high. YI cut‐offs and manufacturer (MA) cut‐offs were highly consistent. However, for the ECLIA platform (Elecsys®), the YI cut‐off led to significantly higher sensitivity for tTau (97.8% [0.88‐1.00%]/ 80.9%) and pTau181 (97.8% [0.88‐1.00%]/ 83.0%), and higher specificity for Aβ42 (96.0% [79‐100%]/ 76.0%), than MA cut‐off, maybe due to high prevalence of AD. The two fully automated platforms showed markedly reduced maximal coefficients of variation (CV) than ELISA.Conclusion: In addition to increased time efficiency, fully automated platforms showed more consistent results than ELISA assays which favor single analyte measurements. Improved accuracy using YI cut‐offs suggests that in‐house cut‐offs might be important for optimal performance. The two fully automated platforms had comparable accuracy. Thus, the platform of choice might depend on the user’s needs; for instance, the pTau181/Aβ42 ratio (Elecsys®; (AUC: 1.0 [1.0‐1.0], sensitivity 100%, specificity 100%)) combines the two AD hallmarks (A and T) in one test. For ATN classification, the Aβ42/Aβ40 ratio (Lumipulse®, AUC: 1.0 [1.0‐1.0], sensitivity 100%, specificity 100%) might be a more accurate marker for amyloid positivity (A+) than Aβ42 alone.

Background: Increasing clinical evidence shows significant drainage of cerebrospinal fluid (CSF) and its metabolites along the olfactory route into the nose. Nasal secretion‐based analysis of key Alzheimer biomarkers was compared to CSF‐based analysis in different cohorts.Method: We conducted a multicenter, prospective cohort study involving patients with cognitive impairment and availability of CSF measurement of the 4 AD‐specific proteins. Cohorts were defined based on CSF biomarker classification following NIA‐AA ATN research diagnostic framework and clinical findings. Nasal secretion (NS) was collected from the vicinity of the olfactory cleft. [NosetestAD] was performed for subsequent in vitro analysis.Result: For this analysis, 39 patients with cognitive impairment were included at 3 university clinics in Germany. The nasal sampling procedure [noseabsorb] is painless (VAS 2 ±1.7) and yields a high sample volume (mean 450 μl). [NosetestAD] allows for precise quantification in size and relative protein amount of AD biomarkers pTau181, total Tau, Amyloid‐ß1‐40 and Amyloid‐ß1‐42. By using an automated protein separation and immunodetection system, we are able to generate a protein specific biomarker signature for all 4 AD‐associated proteins (pTau, tTau, Aß42,Aß40) characterizing parameters such as oligomerization state and relative protein amount. Further, a highly significant discrimination of amyloid pathology (A+ vs. A‐) was achieved with an AUC of 0.94 and p‐value <0.001.Conclusion: Nasal secretion constitutes a safe, minimally invasive access to CSF. Therefore, it is highly suitable for detection and monitoring of AD relevant biomarkers. Within a cohort of patients with cognitive impairment A+ patients can be distinguished from A‐ patients based on their diseases state specific individual protein‐specific biomarker signatures and the different levels of oligomeric or monomeric structures. Thus, our proprietary diagnostic platform, detects and assesses a broad panel of brain derived biomarkers simultaneously and allows for intraindividual monitoring and possibly disease staging in nasal secretion.