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Preliminary Communication |

Association of a Functional Polymorphism in the Cholesteryl Ester Transfer Protein (CETP) Gene With Memory Decline and Incidence of Dementia FREE

Amy E. Sanders, MD; Cuiling Wang, PhD; Mindy Katz, MPH; Carol A. Derby, PhD; Nir Barzilai, MD; Laurie Ozelius, PhD; Richard B. Lipton, MD
[+] Author Affiliations

Author Affiliations: Departments of Neurology (Drs Sanders, Derby, and Lipton and Ms Katz) and Epidemiology and Population Health (Drs Wang, Derby, and Lipton) and Institute for Aging Research (Drs Barzilai and Lipton), Albert Einstein College of Medicine, Yeshiva University, Bronx, New York; and Departments of Genetics and Genomic Sciences and Neurology, Mount Sinai School of Medicine, New York, New York (Dr Ozelius).


JAMA. 2010;303(2):150-158. doi:10.1001/jama.2009.1988.
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Published online

Context Polymorphisms in the cholesteryl ester transfer protein (CETP) gene have been associated with exceptional longevity and lower cardiovascular risk, but associations with memory decline and dementia risk are unclear.

Objective To test the hypothesis that a single-nucleotide polymorphism (SNP) at CETP codon 405 (isoleucine to valine V405; SNP rs5882) is associated with a lower rate of memory decline and lower risk of incident dementia, including Alzheimer disease (AD).

Design, Setting, and Participants Prospective cohort study comprising 608 community-dwelling adults without dementia aged 70 years or older from the Einstein Aging Study with CETP genotype available. Fifteen participants with prevalent dementia were excluded, and 70 without follow-up—63 lost to follow-up and 7 new to the study—were excluded from the Cox proportional hazards model, which included 523 participants in the analysis. Standardized neuropsychological and neurological measures were administered annually from 1994-2009. Linear mixed-effects models adjusted for sex, education, race, medical comorbidities, and apolipoprotein (APOE) ε4 examined associations of V405 genotype with longitudinal performance on cognitive tests of episodic memory (Free and Cued Selective Reminding Test [FCSRT], possible scores of 0-48), attention (Digit Span), and psychomotor speed (Digit Symbol Substitution). The V405 genotype was the main predictor of incident dementia or AD in similarly adjusted Cox proportional hazards models with age as the time scale.

Main Outcome Measures Memory decline and incident dementia.

Results Valine allele frequency was 43.5%. A total of 40 cases of incident dementia occurred during follow-up (mean [(SD], 4.3 [3.1] years). Compared with isoleucine homozygotes, valine homozygotes had significantly slower memory decline on the FCSRT (0.43 points per year of age for isoleucine; 95% confidence interval [CI], −0.58 to −0.29 vs 0.21 points per year of age for valine; 95% CI, −0.39 to −0.04; difference in linear age slope, 0.22; 95% CI, 0.02 to 0.41; P = .03) and no significant differences on the Digit Span or Digit Symbol Substitution tests. Valine homozygotes also had lower risk of dementia (hazard ratio, 0.28; 95% CI, 0.10-0.85; P = .02) and AD (hazard ratio, 0.31; 95% CI, 0.10-0.95; P = .04).

Conclusion This preliminary report suggests that CETP V405 valine homozygosity is associated with slower memory decline and lower incident dementia and AD risk.

Figures in this Article

As the population ages, the public health and economic burdens of age-associated cognitive decline and dementia will continue to increase. Only the apolipoprotein (APOE [ε4 isoform]) has been conclusively associated with increased genetic susceptibility for the most common dementia, sporadic late-onset Alzheimer disease (AD).1 Genes identified through associations with exceptional longevity are logical targets to explore for potentially beneficial associations with cognitive decline and dementia risk.2

Some studies have suggested that the APOE ε2 allele is associated with both increased lifespan and lower dementia risk.3 Like APOE, the cholesteryl ester transfer protein gene (CETP) is involved in central nervous system cholesterol homeostasis and has been associated with exceptional longevity.4,5 At codon 405 (exon 14), a functional single-nucleotide polymorphism (SNP) substitutes valine (V) for isoleucine (I; “ancestral allele”; NCBI SNP rs5882; V405) and is associated with lower CETP protein serum concentration and activity and corresponding increases in high-density lipoprotein (HDL) levels and lipoprotein (HDL/LDL [low-density lipoprotein]) particle sizes.4,6 These changes may have additional protective associations with cardiovascular disease, although the precise nature and potential mediators of these relationships are debated.7,8

The CETP gene was identified as a “longevity gene” in a sample of Ashkenazi Jews by Barzilai and colleagues4 in 2003: valine homozygosity occurred in 24.8% of centenarians compared with 8.6% among controls. In a cross-sectional follow-up study, Ashkenazi centenarians with good cognitive function had increased frequency of the V405 polymorphism; in an independent cohort valine homozygosity was approximately 5-fold higher in Ashkenazi individuals aged 75 to 85 years without dementia compared with those with dementia.2 Case-control studies in non-Ashkenazi populations have also reported protective associations between CETP SNPs and dementia prevalence, although replication has been inconsistent.811

Herein, we investigated associations between V405 genotype and longitudinal memory performance and risk for incident dementia or AD in a community-based sample of healthy older adults without dementia at baseline. We hypothesized that the valine allele would be associated with less age-associated memory decline and lower risk of incident dementia.

Participants

The Einstein Aging Study is a prospective cohort study designed to identify factors predicting cognitive decline and incident dementia in a racially and ethnically diverse community-dwelling population of elderly individuals. Study design and methods for recruitment and annual assessments have been previously described.12,13 Briefly, potential participants were systematically recruited from population lists of Medicare recipients (1994-2004) or Bronx County registered voters (2004-2009). Eligible participants were aged 70 years or older, resided in the Bronx, and had sufficient command of English to participate in neuropsychological testing. Exclusion criteria included audiovisual impairment severe enough to interfere with cognitive testing, inability to ambulate, and institutionalization. Written informed consent was obtained from each individual at study entry according to protocols approved by the institutional review board of the Albert Einstein College of Medicine. Annual in-person evaluations occurred at the Einstein Aging Study Aging Research Center located on the Einstein campus.

Since 1994, the Einstein Aging Study has enrolled 1910 individuals; 1215 consented to have blood samples drawn and 608 had DNA extracted and genotyping performed. Availability of CETP and APOE genotypes determined preliminary eligibility for this investigation (n = 608). Participants with dementia at baseline (n = 15) were excluded from all analyses (n = 593). Those without follow-up visits (n = 70) were additionally excluded from the incident dementia analysis (n = 523). Compared with 523 included individuals, the 70 excluded for lack of follow-up did not differ statistically in age (78.5 vs 78.4 years, P = .81), sex (61% vs 63% women, P = .76), race (69% vs 67% white, P = .75; 26% vs 27% African American, P = .78), educational level (13.9 vs 14.4 years, P = .64), baseline cognition (Blessed Information Memory Concentration score, 2.1 vs 1.9, P = .88), or genotype frequency for APOE ε4 (22% vs 28%, P = .34) or CETP (valine homozygotes 21% vs 14% and valine heterozygotes, 45% vs 60%, P = .06). Reasons for lack of follow-up included interval occurrence of an exclusion criterion after study entry (n = 3), moved (n = 4), became too ill to continue (n = 6), loss of contact (n = 6), less than a year as a study participant (n = 7), death (n = 12), and declined or unavailable to continue (n = 32).

Of the 607 individuals with blood samples but no genotype performed, long-banked buffy coat did not yield high-quality DNA for 174 participants, so these individuals were excluded from the current analysis, as were 33 individuals with prevalent dementia. Two hundred twenty-seven have had only their baseline visit and consequently no follow-up data are available. Because this is an ongoing cohort study with analyses being continuously performed, a total of 173 samples remain to be genotyped. Statistical comparison between individuals with and without genotyping revealed that the 2 groups were similar in sex and racial distribution, but those who were genotyped were significantly younger with a mean (SD) age of 78.6 (5.2) vs 79.5 (5.5) years (P <.001); better educated, 14.0 (3.5) vs 12.5 (3.6) years of education (P <.001); and at baseline had better global cognitive function scores, 2.2 (2.2) vs 3.9 (3.8) measured by the Blessed Information Memory Concentration test (P <.001) and better episodic memory performance, 30.6 (6.2) vs 28.0 (8.1), on the Free and Cued Selective Reminding Test (FCSRT) (P <.001) than those who were not genotyped.

Demographic and Clinical Information

Trained research assistants used structured questionnaires to obtain sociodemographic information (age, sex, race, Ashkenazi heritage, and years of education) and medical history at each annual visit. We obtained information on race and ethnicity to explore possible confounding by genetic admixture. Participants self-identified their race/ethnicity and religious background to the research assistants who asked “To which race group do you belong?” and “What is your religious preference?” Because the CETP gene was associated with longevity in Ashkenazi Jews and because our current sample was not restricted to Ashkenazi Jews, we used an indicator variable to adjust for Ashkenazi heritage in both longitudinal analyses. Response options for race/ethnicity were white, black, Hispanic/white, Hispanic/black, Asian, or other. For religious background, options were Protestant, Catholic, Jewish, or other; individuals could decline to endorse a preference. Using baseline medical history, we tabulated a medical comorbidity index score (range, 0-10) from dichotomous self-report (present vs absent) of hypertension, diabetes, angina, myocardial infarction, congestive heart failure, stroke, Parkinson disease, rheumatoid arthritis, chronic obstructive pulmonary disease, and depression.14 Depressive symptoms were assessed using the 15-item Geriatric Depression Scale.15 Functional status was assessed using the Lawton-Brody scale of instrumental activities of daily living (range, 0-8; higher scores better).16

Neuropsychological Assessment

At baseline and at each annual evaluation, cognitive status was assessed by a comprehensive neuropsychological battery comprising tests of global cognition and the specific cognitive domains of attention, episodic and visual memory, executive function, language, and visuoconstructional ability.17 Administration by trained neuropsychological assistants was standardized according to Einstein Aging Study protocols based on published guidelines. For this study, we report premorbid intelligence, global cognitive status, and results from representative domain-specific cognitive tests of attention, psychomotor speed, and episodic memory. The vocabulary subtest from the Wechsler Adult Intelligence Scale-Revised (WAIS-R) served as a “hold” test, estimating crystallized intelligence less vulnerable to the effects of aging and not expected to decline as a consequence of dementia.18 Global cognition was assessed via the Blessed Information Memory Concentration test, which correlates well with AD neuropathology.19,20 Domain-specific cognitive tests were the Digit Span and Digit Symbol Substitution WAIS-R18 subtests, and free recall was assessed with the FCSRT.21,22 We selected the FCSRT to test our a priori hypothesis of a protective association between V405 genotype and episodic memory based on its demonstrated operating characteristics.2325 Digit Span was used to assess attention, which is unlikely to decline as a result of dementia and when impaired is more commonly a consequence of cerebrovascular disease.26 Digit Symbol Substitution was chosen as a test of psychomotor processing speed, which may exhibit age-associated decline but is less sensitive to dementia.27

Dementia Diagnosis

The Einstein Aging Study neuropsychologist and neurologist met monthly in diagnostic consensus case conferences that included review of all available clinical and neuropsychological data.28 Dementia diagnoses were based on standardized clinical criteria from the Diagnostic and Statistical Manual (Fourth Edition) (DSM-IV)29 and required impairment in memory plus at least 1 additional cognitive domain, accompanied by evidence of functional decline. Alzheimer disease was diagnosed in participants with dementia who met clinical criteria for probable or possible disease established by the National Institute of Neurological and Communicative Disorders and Stroke and the Alzheimer Disease and Related Disorders Association.30

Genotyping

All blood samples for genotyping were obtained after participants gave written informed consent. The phlebotomist drew 20 mL of whole blood at the Aging Research Center; samples were centrifuged and stored in aliquots in a −70°C freezer. Subsequently, DNA was isolated directly from buffy coat using the Puregene DNA Purification System (Gentra System, Minneapolis, Minnesota). Amplification and sequencing primers for genotyping of the target V405 SNP (rs5882) and for the 2 APOE SNPs, rs429358 (position 112) and rs7412 (position 158), were designed using PSQ version 1.0.6 software (Biotage, Uppsala, Sweden); in each case the reverse primer was biotinylated. Genotyping was performed using a Pyrosequencing PSQ HS 96A system (http://www.pyrosequencing.com) according to manufacturer's instructions.

Statistical Analysis

We classified participants dichotomously based on whether incident dementia occurred during follow-up. Time of dementia diagnosis was assigned the visit date immediately preceding the consensus conference making the diagnosis. The V405 genotype was dichotomized into homozygote (V-V) and heterozygote (I-V) groups; isoleucine homozygotes served as the reference group in all longitudinal analyses. Baseline demographic and clinical characteristics were compared using either the Wilcoxon rank sum or Kruskal-Wallis tests for continuous variables; χ2 or Fisher exact tests were used as appropriate for categorical variables.

Associations between V405 genotype and longitudinal performance in episodic memory, attention, and psychomotor speed were examined with linear mixed-effects models using age (centered at 85 years) as the time scale and adjusted for sex, educational level, race/ethnicity, and presence of an APOE ε4 allele. Indicator variables coded for African American race and Ashkenazi heritage. The V405 genotype groups were separately compared with the isoleucine reference group. The main outcome of interest was repeated measures of individual free recall scores on the FCSRT. For each V405 group the β coefficient for the difference in linear age slope estimated the change in cognitive score per additional year of age compared with the reference group. A quadratic age term tested whether an accelerated nonlinear trend was present. Performance on tests of attention and psychomotor speed were similarly modeled.

To estimate the risk of incident dementia and AD as a function of the V405 group, we used nested Cox proportional hazard models with delayed entry and age as the time scale.31 In cohort studies, age is preferred to follow-up time as the time scale because the hazard function can be directly interpreted as the age-specific incidence function for dementia; inclusion of age as a nonparametric term in this manner provides a more flexible and effective control than treating age as a covariate.31 Hazard ratios (HRs) were estimated using the V405 groups as categorical predictor variables, with isoleucine homozygotes as the reference. Time to event was the interval between age at baseline and age at dementia or AD diagnosis or last contact, as appropriate. In model 1, we adjusted for sex, race/ethnicity (coded as above), and years of education. Model 2 included the covariates in model 1 plus an additional adjustment for the medical comorbidity index. Model 3 included all covariates from models 1 and 2, plus an additional adjustment for presence of an APOE ε4 allele. To assess potentially competing cardiovascular morbidity, we reran the final model substituting combined history of hypertension, myocardial infarction, and stroke for the comorbidity index. All covariates were preselected based on biological plausibility, potential for confounding, or both and were used as time-constant covariates. Proportional hazards assumptions of the models were examined using methods based on scaled Schoenfeld residuals and were adequately met.32

To determine whether missing data on genotype information biased our results, we performed a multiple imputation analysis that gave unbiased estimates under a missing-at-random missing data mechanism, allowing for missing CETP data to depend on incident dementia and covariates but not on unobserved genotype.

We performed a post hoc calculation of the study's power to detect incident dementia and memory decline. Given 21% prevalence for valine homozygosity, the sample of 523 participants with 40 incident dementia cases provided 75% power to detect an HR of 0.3 between valine homozygotes and the isoleucine reference group. For smaller effect sizes, such as HRs closer to 1, power would be lower. For memory decline, the data provide 57% power to detect a difference of 0.2 points per year in linear age slope on the FCSRT.

The statistical software packages SAS version 9.1 (SAS Institute Inc, Cary, North Carolina) and S-Plus 8.0 (Insightful Corp, Seattle, Washington) were used for all analyses. Two-sided probability values less than .05 were considered statistically significant in all tests, including the Fisher exact test.

Demographic Characteristics

In the study sample of 523 individuals, 40 incident cases of dementia occurred (Table 1). Frequency of the APOE ε4 allele (23%) was similar to other racially and ethnically diverse cohorts in US urban centers.33,34 At first evaluation, compared with individuals who did not develop dementia throughout follow-up, those who developed dementia were older, less educated, and had poorer performance in global cognition, psychomotor speed, and episodic memory. The groups did not differ by sex, race, Ashkenazi heritage, CETP or APOE genotype, or medical comorbidity burden.

Table Graphic Jump LocationTable 1. Baseline Characteristics of Study Population by Dementia Status at Follow-upa

Allele frequency for valine was 43.5% for the study cohort: 235 of the 523 participants (45%) were heterozygotes; 110 (21%) were valine homozygotes; and 178 (34%) were isoleucine homozygotes. Genotype frequencies differed marginally from Hardy-Weinberg equilibrium (χ21 = 3.86, P = .05), possibly consistent with a longevity effect on allele distribution.35,36 Demographic characteristics and baseline neuropsychological test results among the 3 genotype groups were similar except for premorbid intelligence and race/ethnicity (Table 2). Compared with 37% in whites, valine frequency was 60% in African Americans, similar to frequencies previously reported elsewhere.37 African Americans were a median age of 77.2 years (interquartile range [IQR], 7.6 years]) vs 78.3 years (IQR, 8.2 years) among non–African Americans, and the proportion of women was greater in the African American (79%) than non–African American (55%) group (P<.001). African Americans had a median of 12.5 years of education (IQR, 4.0; range, 3-20 years) vs 14.0 years (IQR, 4.0; range, 4-22 years) among non–African Americans (P = .001), a median baseline Blessed Information Memory Concentration score of 3.0 (IQR, 4.0; range, 0-8) vs 1.0 (IQR, 3.0; range, 1-10) among non–African Americans (P < .001), and a higher percentage with an APOE ε4 allele (31% vs 23%, P = .008) than non–African Americans. The median baseline medical comorbidity index scores were similar among groups: 1 (IQR, 1; range, 0-6) for African Americans and 1 (IQR, 1; range, 0-5) for non–African Americans. Ninety-three African Americans (69%) reported hypertension vs 224 non–African Americans (58%) (P = .02), but only 4 (3%) African Americans reported myocardial infarction vs 39 (10%) non–African Americans (P = .01). Rate of self-reported stroke was similar: 13 (10%) African Americans vs 32 (9%) non–African Americans (P = .60). Crude dementia incidence rates among African Americans (2.04 per 100 person-years) were higher than in non–African Americans (1.69 per 100 person-years), but the difference was not statistically significant (P = .18).

Table Graphic Jump LocationTable 2. Characteristics of All Individuals at First Evaluation, Stratified by Cholesteryl Ester Transfer Protein V405 Genotypea
Associations Between CETP Genotype and Longitudinal Cognitive Performance

Baseline performance on the domain-specific cognitive tests of FCSRT, Digit Span, and Digit Symbol Substitution was similar among the 3 genotype groups (Table 2). In the linear mixed-effects model (Table 3), after adjustments for sex, race/ethnicity, education, medical comorbidities, and APOE status, valine homozygosity was independently associated with slower decline on the FCSRT. A quadratic trend for age was found for cognitive decline for both homozygotes and heterozygotes. Compared with an absolute linear age slope of 0.43 points per year of age (95% confidence interval [CI], −0.58 to −0.29) decline in FCSRT score in the reference group, the linear age slope in valine homozygotes was 0.22 points per year of age (95% CI, −0.39 to 0.04). Based on the difference in linear age slopes, valine homozygosity was independently associated with 0.22 points per year of age less decline on FCSRT, slower by a relative 51%. Memory decline in valine heterozygotes was similar to that of the reference group. The V405 genotype was not associated with cognitive performance on domain-specific tests of Digit Span or Digit Symbol Substitution.

Table Graphic Jump LocationTable 3. Estimated Mean Change in Free and Cued Selective Reminding Score With Increasing Age, According to CETP V405 Genotype Groupa
Associations Between CETP Genotype and Incidence of Dementia and Alzheimer Disease

Of the 40 individuals with incident dementia, 35 met criteria for probable or possible Alzheimer disease. In the fully adjusted models (Table 4 and Figure), valine homozygosity was associated with lower risk of developing both dementia and AD. The HRs for heterozygotes were also less than 1 for both dementia and AD but were not statistically significant. Substituting combined history of hypertension, myocardial infarction, and stroke for the comorbidity index in models for dementia slightly reduced the HRs further by a small margin (HR, 0.26; 95% CI, 0.09-78; P = .02 for valine homozygotes; HR, 0.54; 95% CI, 0.27-1.1; P = .09 for heterozygotes).

Place holder to copy figure label and caption
Figure. Incidence of Dementia and Alzheimer Disease by CETP Genotype Group
Graphic Jump Location

A, Dementia incidence by CETP genotype group survival curves are based on the Cox proportional hazards regression analysis. B, Alzheimer disease incidence by CETP genotype group survival curves are based on the Cox proportional hazards regression analysis.

Table Graphic Jump LocationTable 4.CETP V405 Genotype and Risk for Dementia and Alzheimer Diseasea

To address the possibility that racial admixture was confounding our observations, we reran the linear mixed-effects and the final Cox proportional hazards models (minus the indicator variable for African American race) in a white-only subgroup (361 individuals, 24 incident dementia cases). Among whites, valine homozygotes declined more slowly than the reference group on the FCSRT, with a difference of 0.14 points per year of age in the linear age slopes, although the difference was not statistically significant (P=.29; 95% CI, −0.12 to 0.40). In the Cox model of dementia incidence, the magnitude of the association lessened slightly compared with main results and the model was not statistically significant (HR, 0.45; 95% CI, 0.10-2.03; P = .30 for homozygotes; HR, 0.56; 95% CI, 0.23-1.38; P = .21 for heterozygotes), possibly related to lower power.

Because genotype results were not available for all individuals with blood samples, we compared dementia-free survival in those with and without genotype information. Adjusted for sex, education, race, and baseline Blessed Information Memory Concentration score, the genotyped individuals survived longer without dementia than those without genotype information (HR, 0.45; P < .001), suggesting that genotype was not missing at random. In the multiple imputation analysis performed to allay the resulting concerns about the representativeness of our sample and the generalizability of our results, the HR for valine homozygotes was 0.44 (95% CI, 0.20-0.96; P = .04), similar to results observed in the primary analysis.

Compared with a reference group homozygous for the ancestral allele in the full sample, valine homozygosity was independently associated with slower age-associated memory decline and lower risk of incident dementia and Alzheimer disease. Main findings were statistically significant in adjusted models that included APOE status. As assessed by FCSRT, memory declined in valine homozygotes by 0.22 points per year more slowly (relative 51%) than in the reference group; homozygosity was associated with lower risk of both dementia and AD. The HR for dementia and AD was lower in valine heterozygotes than individuals homozygous for isoleucine, but the difference was not statistically significant.

In the analysis of cognitive decline, our primary hypothesis was that the valine allele would be associated with slower episodic memory decline. To our knowledge, only 1 study has evaluated the CETP V405 polymorphism in the context of cognitive change. Johnson et al9 examined V405 associations with childhood IQ and life-long change in global cognition in a group of Scottish older adults. Specific cognitive domains, including memory, were examined cross-sectionally at age 79 years. They reported that CETP was associated with cardiovascular disease rate but detected no significant global longitudinal or domain-specific cross-sectional cognitive associations. In the present report, valine homozygosity was not associated with cross-sectional cognitive function, but it was associated with slightly slower memory decline. Thus, the longitudinal design of our study may account for the different results we found. Population differences may also contribute because valine was at higher frequency (69%) than in our sample (43.5%).

To our knowledge, this is the first study to examine associations between a CETP genotype and dementia risk in an incidence study. Of 10 case-control studies published since 2004, 3 investigated the V405 polymorphism. The single population-based case-control study reported that the V405 polymorphism was associated with an elevated odds ratio (OR) of 1.67 for AD in non-APOE ε4 carriers.8 A 2005 Spanish study reported that ε4 carriers homozygous for the minor allele of the C-629 A CETP polymorphism had a lower OR (2.33) for AD than ε4 noncarriers (OR, 7.12) but found no association between V405 and AD.10 In 2009, Qureischie and colleagues11 reported lack of association between V405 and AD, although a CETP haplotype including valine was associated with cholesterol profiles in plasma and cerebrospinal fluid. Studies investigating other CETP polymorphisms reveal similar heterogeneous results.

Methodological differences among studies may contribute to the disparate results presented herein. We suggest that selection bias in case-control studies may be particularly problematic for polymorphisms associated with longevity. Case-control studies may be biased by factors associated with duration of disease in prevalent cases with longevity-favoring genotypes because they preferentially include dementia cases with longer survival. Based on enhanced survival, such individuals might be overrepresented among cases, spuriously attenuating any protective associations. For this reason, case-control studies likely underestimate associations between longevity genes and prevalent dementia. Because we focused on incident cases, our cohort study may have circumvented this potential bias. Our results suggest that prospective studies may offer methodological advantages in assessing associations between longevity genes and risk for incident dementia.

Two recent genome-wide association studies comparing AD cases with non-AD controls failed to identify the CETP V405 polymorphism.38,39 This is less surprising than it might appear: in general, genome-wide association studies look for polymorphisms with elevated ORs, indicating a strong association with increased risk of disease. A protective association with V405 may have been dismissed as nonsignificant by current genome-wide association study practices, making it difficult to compare our results with those from traditional dementia genome-wide association studies.

We detected no bivariate association between Ashkenazi heritage and genotype, but race was associated with genotype: although comparable with previously published reports, prevalence of valine was higher in African Americans than whites. African American and non–African American participants were similar in median age and crude dementia incidence rates, but African Americans were more likely to have several known risk factors for dementia, including less educational achievement, poorer baseline global cognition, and higher APOE ε4 frequency. These results might be interpreted as relative protection insofar as there appeared to be higher risk without higher incidence. Conversely, they could be paradoxical, given increased valine allele frequency in African Americans without lower incidence, possibly indicating a genotype-race interaction that this study was not powered to detect. Alternatively, African Americans may possess a third factor that increases dementia susceptibility despite higher population frequencies of the putatively protective allele. We attempted to account for the potential effects of race by including it as a confounder in our models. After excluding African Americans in the Cox models for dementia, the magnitude of the resulting association changed only slightly but lost statistical significance. The low number of incident dementia cases prevented exploration of interactions in race-stratified analyses. These observations merit further investigation.

Our study cannot directly address the nature of causal relationships underlying the associations reported herein, limiting us to informed speculation. Although it remains unknown whether CETP polymorphisms cause specific differential rates of memory decline or dementia incidence, the basic temporal sequence of the genetic factor preceding downstream effects is indisputable. The fact that the HR for valine heterozygotes was between the HR for homozygotes and that of isoleucine homozygotes suggests a possible gene-dose relationship favoring a possible causal relationship. The CETP protein is synthesized40 and expressed41 in brain, but sparse knowledge limits speculation about CETP's role in neurodegenerative pathophysiological mechanisms that might influence dementia risk. Growing evidence posits a mechanistic pathway linking cerebral cholesterol metabolism and AD pathology; hypothetical descriptions include genetic susceptibility conferred by cholesterol-metabolism genes such as CETP and APOE.5,40 Future studies investigating intermediate steps in the putative causal pathway—mediation by endophenotypic biomarkers, such as CETP plasma levels and protein activity, for example—might provide useful first steps toward eventual resolution of the causality question.

There are several caveats to our results. Although APOE frequency in our sample was comparable with other aging cohorts, our participants were nevertheless community-residing relatively healthy older adults living in the Bronx and we acknowledge the need to evaluate the CETP gene in other longitudinal studies with greater numbers of incident dementia cases. We used well-established procedures and standardized criteria to diagnose dementia and AD, but some misclassification may have occurred. Like any longitudinal study, ours may have had selective attrition, although the duration of follow-up helps allay this concern. At 40, the number of incident dementia cases was small. The amount of reduction in memory decline associated with a valine homozygous state was small—0.22 points per year on a scale ranging from 0 to 48.

Despite the small number of incident dementia cases and small decline in memory, this preliminary report suggests that CETP valine homozygosity is associated with slower memory decline and lower risk for incident dementia or AD. This potentially protective association is supported by several observations. First, some (but not all) prior work has shown that at cross-section valine homozygosity was associated with better mental status.2 Second, valine homozygosity is associated with a slower rate of memory decline in our entire sample, not just those who developed dementia. Third, the HRs in this analysis suggested a possible gene-dose relationship for the CETP gene. Finally, an association between CETP status and cognition and dementia is biologically plausible because other genes involved in lipid metabolism, including APOE, are associated with dementia risk. Future studies should further evaluate the potential protective association of the CETP gene with dementia risk.

Corresponding Author: Richard B. Lipton, MD, Einstein Aging Study, Albert Einstein College of Medicine, Yeshiva University, 1165 Morris Park Ave, Rousso Bldg, Room 346, Bronx, NY 10461 (richard.lipton@einstein.yu.edu).

Author Contributions: Dr Lipton had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Lipton, Sanders, Barzilai, Katz, Derby.

Acquisition of data: Lipton, Ozelius, Derby, Katz.

Analysis and interpretation of data: Lipton, Sanders, Wang, Derby, Katz.

Drafting of the manuscript: Sanders, Lipton.

Critical revision of the manuscript for important intellectual content: Lipton, Sanders, Ozelius, Wang, Derby, Katz, Barzilai.

Statistical analysis: Wang, Lipton, Sanders, Katz.

Obtained funding: Lipton.

Administrative, technical, or material support: Lipton, Katz, Sanders, Ozelius.

Study supervision: Lipton.

Financial Disclosures: Dr Lipton reported receiving compensation from Advanced Bionics, Allergan, Astra-Zeneca, Bayer, Boehringer-Ingelheim, Bristol-Myers Squibb, Cierra, Endo, GlaxoSmithKline, Minster, Merck, Neuralieve, Novartis, and Ortho-McNeil and receiving research funding from Allergan, Ortho-McNeil, Minster, Endo, GlaxoSmithKline, Merck, Neuralieve, and ProEthics. None of these relationships pertain to the material presented in this study. No other financial disclosures were reported.

Funding/Support: The Einstein Aging Study is supported by the National Institute on Aging program project grant AG03949 and Supplement (Biorepository) AG03949-24S1. Dr Barzilai is supported by grants AG-027734 and AG-18728 from the National Institute on Aging. Dr Sanders is supported by the Einstein Clinical and Translation Science Award grant UL1 RR025750 and KL2 RR025749 and TL1 RR025748 from the National Center for Research Resources (NCRR), a component of the National Institutes of Health (NIH), and NIH Roadmap for Medical Research.

Role of the Sponsor: The National Institute on Aging had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript.

Disclaimer: The contents of this article are solely the responsibility of the authors and do not necessary represent the official view of the NCRR or NIH.

Previous Presentation: This work was presented in part at the 61st annual meeting of the American Academy of Neurology; Seattle, Washington; April 25-May 2, 2009.

Coon KD, Myers AJ, Craig DW,  et al.  A high-density whole-genome association study reveals that APOE is the major susceptibility gene for sporadic late-onset Alzheimer's disease.  J Clin Psychiatry. 2007;68(4):613-618
PubMed   |  Link to Article
Barzilai N, Atzmon G, Derby CA, Bauman JM, Lipton RB. A genotype of exceptional longevity is associated with preservation of cognitive function.  Neurology. 2006;67(12):2170-2175
PubMed   |  Link to Article
Schächter F, Faure-Delanef L, Guénot F,  et al.  Genetic associations with human longevity at the APOE and ACE loci.  Nat Genet. 1994;6(1):29-32
PubMed   |  Link to Article
Barzilai N, Atzmon G, Schechter C,  et al.  Unique lipoprotein phenotype and genotype in humans with exceptional longevity.  JAMA. 2003;290(15):2030-2040
PubMed   |  Link to Article
Carter CJ. Convergence of genes implicated in Alzheimer's disease on the cerebral cholesterol shuttle: APP, cholesterol, lipoproteins, and atherosclerosis.  Neurochem Int. 2007;50(1):12-38
PubMed   |  Link to Article
Thompson A, Di Angelantonio E, Sarwar N,  et al.  Association of cholesteryl ester transfer protein genotypes with CETP mass and activity, lipid levels, and coronary risk.  JAMA. 2008;299(23):2777-2788
PubMed   |  Link to Article
Dullaart RP, Sluiter WJ. Common variation in the CETP gene and the implications for cardiovascular disease and its treatment: an updated analysis.  Pharmacogenomics. 2008;9(6):747-763
PubMed   |  Link to Article
Arias-Vásquez A, Isaacs A, Aulchenko YS,  et al.  The cholesteryl ester transfer protein (CETP) gene and the risk of Alzheimer's disease.  Neurogenetics. 2007;8(3):189-193
PubMed   |  Link to Article
Johnson W, Harris SE, Collins P, Starr JM, Whalley LJ, Deary IJ. No association of CETP genotype with cognitive function or age-related cognitive change.  Neurosci Lett. 2007;420(2):189-192
PubMed   |  Link to Article
Rodríguez E, Mateo I, Infante J, Llorca J, Berciano J, Combarros O. Cholesteryl ester transfer protein (CETP) polymorphism modifies the Alzheimer's disease risk associated with APOE epsilon 4 allele.  J Neurol. 2006;253(2):181-185
PubMed   |  Link to Article
Qureischie H, Heun R, Popp J,  et al.  Association of CETP polymorphisms with the risk of vascular dementia and white matter lesions.  J Neural Transm. 2009;116(4):467-472
PubMed   |  Link to Article
Lipton RB, Katz MJ, Kuslansky G,  et al.  Screening for dementia by telephone using the memory impairment screen.  J Am Geriatr Soc. 2003;51(10):1382-1390
PubMed   |  Link to Article
Verghese J, LeValley A, Hall CB, Katz MJ, Ambrose AF, Lipton RB. Epidemiology of gait disorders in community-residing older adults.  J Am Geriatr Soc. 2006;54(2):255-261
PubMed   |  Link to Article
Verghese J, Ambrose AF, Lipton RB, Wang C. Neurological gait abnormalities and risk of falls in older adults [published online September 26, 2009].  J Neurol
PubMed  |  Link to Article
Sheikh JI, Yesavage JA. Geriatric Depression Scale (GDS): recent evidence and development of a shorter version.  Clin Gerontol. 1986;5(1/2):165-173Link to Article
Lawton MP, Brody EM. Assessment of older people: self-maintaining and instrumental activities of daily living.  Gerontologist. 1969;9(3):179-186
PubMed   |  Link to Article
Masur DM, Sliwinski M, Lipton RB, Blau AD, Crystal HA. Neuropsychological prediction of dementia and the absence of dementia in healthy elderly persons.  Neurology. 1994;44(8):1427-1432
PubMed   |  Link to Article
Wechsler D. Wechsler Adult Intelligence Scale—Revised. New York, NY: Psychological Corp; 1981
Blessed G, Tomlinson BE, Roth M. The association between quantitative measures of dementia and of senile change in the cerebral grey matter of elderly subjects.  Br J Psychiatry. 1968;114(512):797-811
PubMed   |  Link to Article
Grober E, Dickson D, Sliwinski MJ,  et al.  Memory and mental status correlates of modified Braak staging.  Neurobiol Aging. 1999;20(6):573-579
PubMed   |  Link to Article
Buschke H. Cued recall in amnesia.  J Clin Neuropsychol. 1984;6(4):433-440
PubMed   |  Link to Article
Grober E, Buschke H, Crystal H, Bang S, Dresner R. Screening for dementia by memory testing.  Neurology. 1988;38(6):900-903
PubMed   |  Link to Article
Tounsi H, Deweer B, Ergis AM,  et al.  Sensitivity to semantic cuing: an index of episodic memory dysfunction in early Alzheimer disease.  Alzheimer Dis Assoc Disord. 1999;13(1):38-46
PubMed   |  Link to Article
Vellas B, Andrieu S, Sampaio C, Coley N, Wilcock G.European Task Force Group.  Endpoints for trials in Alzheimer's disease: a European task force consensus.  Lancet Neurol. 2008;7(5):436-450
PubMed   |  Link to Article
Grober E, Sanders AE, Hall C, Lipton RB. Free and cued selective reminding identifies very mild dementia in primary care. Alzheimer Dis Assoc Disord. In press
Suribhatla S, Baillon S, Dennis M,  et al.  Neuropsychological performance in early and late onset Alzheimer's disease: comparisons in a memory clinic population.  Int J Geriatr Psychiatry. 2004;19(12):1140-1147
PubMed   |  Link to Article
Proust-Lima C, Amieva H, Dartigues JF, Jacqmin-Gadda H. Sensitivity of four psychometric tests to measure cognitive changes in brain aging-population-based studies.  Am J Epidemiol. 2007;165(3):344-350
PubMed   |  Link to Article
Sanders AE, Holtzer R, Lipton RB, Hall C, Verghese J. Egocentric and exocentric navigation skills in older adults.  J Gerontol A Biol Sci Med Sci. 2008;63(12):1356-1363
PubMed   |  Link to Article
American Psychiatric Association.  Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994:133
McKhann G, Drachman D, Folstein M, Katzman R, Price D, Stadlan EM. Clinical diagnosis of Alzheimer's disease: report of the NINDS-ADRDA Work Group under the auspices of Department of Health and Human Services Task Force on Alzheimer's Disease.  Neurology. 1984;34(7):939-944
PubMed   |  Link to Article
Thiébaut AC, Benichou J. Choice of time-scale in Cox's model analysis of epidemiologic cohort data: a simulation study.  Stat Med. 2004;23(24):3803-3820
PubMed   |  Link to Article
Grambsch PM, Therneau TM. Proportional hazards tests and diagnostics based on weighted residuals.  Biometrika. 1994;81:515-526Link to Article
Link to Article
Scarmeas N, Luchsinger JA, Schupf N,  et al.  Physical activity, diet, and risk of Alzheimer disease.  JAMA. 2009;302(6):627-637
PubMed   |  Link to Article
Bennett DA, De Jager PL, Leurgans SE, Schneider JA. Neuropathologic intermediate phenotypes enhance association to Alzheimer susceptibility alleles.  Neurology. 2009;72(17):1495-1503
PubMed   |  Link to Article
Tan Q, De Benedictis G, Yashin AI,  et al.  Assessing genetic association with human survival at multi-allelic loci.  Biogerontology. 2004;5(2):89-97
PubMed   |  Link to Article
Martin GM, Bergman A, Barzilai N. Genetic determinants of human health span and life span: progress and new opportunities.  PLoS Genet. 2007;3(7):e125
PubMed   |  Link to Article
Thompson JF, Durham LK, Lira ME, Shear C, Milos PM. CETP polymorphisms associated with HDL cholesterol may differ from those associated with cardiovascular disease.  Atherosclerosis. 2005;181(1):45-53
PubMed   |  Link to Article
Harold D, Abraham R, Hollingworth P,  et al.  Genome-wide association study identifies variants at CLU and PICALM associated with Alzheimer's disease.  Nat Genet. 2009;41(10):1088-1093
PubMed   |  Link to Article
Lambert JC, Heath S, Even G,  et al; European Alzheimer's Disease Initiative Investigators.  Genome-wide association study identifies variants at CLU and CR1 associated with Alzheimer's disease.  Nat Genet. 2009;41(10):1094-1099
PubMed   |  Link to Article
Albers JJ, Tollefson JH, Wolfbauer G, Albright RE Jr. Cholesteryl ester transfer protein in human brain.  Int J Clin Lab Res. 1992;21(3):264-266
PubMed   |  Link to Article
Yamada T, Kawata M, Arai H, Fukasawa M, Inoue K, Sato T. Astroglial localization of cholesteryl ester transfer protein in normal and Alzheimer's disease brain tissues.  Acta Neuropathol. 1995;90(6):633-636
PubMed   |  Link to Article

Figures

Place holder to copy figure label and caption
Figure. Incidence of Dementia and Alzheimer Disease by CETP Genotype Group
Graphic Jump Location

A, Dementia incidence by CETP genotype group survival curves are based on the Cox proportional hazards regression analysis. B, Alzheimer disease incidence by CETP genotype group survival curves are based on the Cox proportional hazards regression analysis.

Tables

Table Graphic Jump LocationTable 1. Baseline Characteristics of Study Population by Dementia Status at Follow-upa
Table Graphic Jump LocationTable 2. Characteristics of All Individuals at First Evaluation, Stratified by Cholesteryl Ester Transfer Protein V405 Genotypea
Table Graphic Jump LocationTable 3. Estimated Mean Change in Free and Cued Selective Reminding Score With Increasing Age, According to CETP V405 Genotype Groupa
Table Graphic Jump LocationTable 4.CETP V405 Genotype and Risk for Dementia and Alzheimer Diseasea

References

Coon KD, Myers AJ, Craig DW,  et al.  A high-density whole-genome association study reveals that APOE is the major susceptibility gene for sporadic late-onset Alzheimer's disease.  J Clin Psychiatry. 2007;68(4):613-618
PubMed   |  Link to Article
Barzilai N, Atzmon G, Derby CA, Bauman JM, Lipton RB. A genotype of exceptional longevity is associated with preservation of cognitive function.  Neurology. 2006;67(12):2170-2175
PubMed   |  Link to Article
Schächter F, Faure-Delanef L, Guénot F,  et al.  Genetic associations with human longevity at the APOE and ACE loci.  Nat Genet. 1994;6(1):29-32
PubMed   |  Link to Article
Barzilai N, Atzmon G, Schechter C,  et al.  Unique lipoprotein phenotype and genotype in humans with exceptional longevity.  JAMA. 2003;290(15):2030-2040
PubMed   |  Link to Article
Carter CJ. Convergence of genes implicated in Alzheimer's disease on the cerebral cholesterol shuttle: APP, cholesterol, lipoproteins, and atherosclerosis.  Neurochem Int. 2007;50(1):12-38
PubMed   |  Link to Article
Thompson A, Di Angelantonio E, Sarwar N,  et al.  Association of cholesteryl ester transfer protein genotypes with CETP mass and activity, lipid levels, and coronary risk.  JAMA. 2008;299(23):2777-2788
PubMed   |  Link to Article
Dullaart RP, Sluiter WJ. Common variation in the CETP gene and the implications for cardiovascular disease and its treatment: an updated analysis.  Pharmacogenomics. 2008;9(6):747-763
PubMed   |  Link to Article
Arias-Vásquez A, Isaacs A, Aulchenko YS,  et al.  The cholesteryl ester transfer protein (CETP) gene and the risk of Alzheimer's disease.  Neurogenetics. 2007;8(3):189-193
PubMed   |  Link to Article
Johnson W, Harris SE, Collins P, Starr JM, Whalley LJ, Deary IJ. No association of CETP genotype with cognitive function or age-related cognitive change.  Neurosci Lett. 2007;420(2):189-192
PubMed   |  Link to Article
Rodríguez E, Mateo I, Infante J, Llorca J, Berciano J, Combarros O. Cholesteryl ester transfer protein (CETP) polymorphism modifies the Alzheimer's disease risk associated with APOE epsilon 4 allele.  J Neurol. 2006;253(2):181-185
PubMed   |  Link to Article
Qureischie H, Heun R, Popp J,  et al.  Association of CETP polymorphisms with the risk of vascular dementia and white matter lesions.  J Neural Transm. 2009;116(4):467-472
PubMed   |  Link to Article
Lipton RB, Katz MJ, Kuslansky G,  et al.  Screening for dementia by telephone using the memory impairment screen.  J Am Geriatr Soc. 2003;51(10):1382-1390
PubMed   |  Link to Article
Verghese J, LeValley A, Hall CB, Katz MJ, Ambrose AF, Lipton RB. Epidemiology of gait disorders in community-residing older adults.  J Am Geriatr Soc. 2006;54(2):255-261
PubMed   |  Link to Article
Verghese J, Ambrose AF, Lipton RB, Wang C. Neurological gait abnormalities and risk of falls in older adults [published online September 26, 2009].  J Neurol
PubMed  |  Link to Article
Sheikh JI, Yesavage JA. Geriatric Depression Scale (GDS): recent evidence and development of a shorter version.  Clin Gerontol. 1986;5(1/2):165-173Link to Article
Lawton MP, Brody EM. Assessment of older people: self-maintaining and instrumental activities of daily living.  Gerontologist. 1969;9(3):179-186
PubMed   |  Link to Article
Masur DM, Sliwinski M, Lipton RB, Blau AD, Crystal HA. Neuropsychological prediction of dementia and the absence of dementia in healthy elderly persons.  Neurology. 1994;44(8):1427-1432
PubMed   |  Link to Article
Wechsler D. Wechsler Adult Intelligence Scale—Revised. New York, NY: Psychological Corp; 1981
Blessed G, Tomlinson BE, Roth M. The association between quantitative measures of dementia and of senile change in the cerebral grey matter of elderly subjects.  Br J Psychiatry. 1968;114(512):797-811
PubMed   |  Link to Article
Grober E, Dickson D, Sliwinski MJ,  et al.  Memory and mental status correlates of modified Braak staging.  Neurobiol Aging. 1999;20(6):573-579
PubMed   |  Link to Article
Buschke H. Cued recall in amnesia.  J Clin Neuropsychol. 1984;6(4):433-440
PubMed   |  Link to Article
Grober E, Buschke H, Crystal H, Bang S, Dresner R. Screening for dementia by memory testing.  Neurology. 1988;38(6):900-903
PubMed   |  Link to Article
Tounsi H, Deweer B, Ergis AM,  et al.  Sensitivity to semantic cuing: an index of episodic memory dysfunction in early Alzheimer disease.  Alzheimer Dis Assoc Disord. 1999;13(1):38-46
PubMed   |  Link to Article
Vellas B, Andrieu S, Sampaio C, Coley N, Wilcock G.European Task Force Group.  Endpoints for trials in Alzheimer's disease: a European task force consensus.  Lancet Neurol. 2008;7(5):436-450
PubMed   |  Link to Article
Grober E, Sanders AE, Hall C, Lipton RB. Free and cued selective reminding identifies very mild dementia in primary care. Alzheimer Dis Assoc Disord. In press
Suribhatla S, Baillon S, Dennis M,  et al.  Neuropsychological performance in early and late onset Alzheimer's disease: comparisons in a memory clinic population.  Int J Geriatr Psychiatry. 2004;19(12):1140-1147
PubMed   |  Link to Article
Proust-Lima C, Amieva H, Dartigues JF, Jacqmin-Gadda H. Sensitivity of four psychometric tests to measure cognitive changes in brain aging-population-based studies.  Am J Epidemiol. 2007;165(3):344-350
PubMed   |  Link to Article
Sanders AE, Holtzer R, Lipton RB, Hall C, Verghese J. Egocentric and exocentric navigation skills in older adults.  J Gerontol A Biol Sci Med Sci. 2008;63(12):1356-1363
PubMed   |  Link to Article
American Psychiatric Association.  Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994:133
McKhann G, Drachman D, Folstein M, Katzman R, Price D, Stadlan EM. Clinical diagnosis of Alzheimer's disease: report of the NINDS-ADRDA Work Group under the auspices of Department of Health and Human Services Task Force on Alzheimer's Disease.  Neurology. 1984;34(7):939-944
PubMed   |  Link to Article
Thiébaut AC, Benichou J. Choice of time-scale in Cox's model analysis of epidemiologic cohort data: a simulation study.  Stat Med. 2004;23(24):3803-3820
PubMed   |  Link to Article
Grambsch PM, Therneau TM. Proportional hazards tests and diagnostics based on weighted residuals.  Biometrika. 1994;81:515-526Link to Article
Link to Article
Scarmeas N, Luchsinger JA, Schupf N,  et al.  Physical activity, diet, and risk of Alzheimer disease.  JAMA. 2009;302(6):627-637
PubMed   |  Link to Article
Bennett DA, De Jager PL, Leurgans SE, Schneider JA. Neuropathologic intermediate phenotypes enhance association to Alzheimer susceptibility alleles.  Neurology. 2009;72(17):1495-1503
PubMed   |  Link to Article
Tan Q, De Benedictis G, Yashin AI,  et al.  Assessing genetic association with human survival at multi-allelic loci.  Biogerontology. 2004;5(2):89-97
PubMed   |  Link to Article
Martin GM, Bergman A, Barzilai N. Genetic determinants of human health span and life span: progress and new opportunities.  PLoS Genet. 2007;3(7):e125
PubMed   |  Link to Article
Thompson JF, Durham LK, Lira ME, Shear C, Milos PM. CETP polymorphisms associated with HDL cholesterol may differ from those associated with cardiovascular disease.  Atherosclerosis. 2005;181(1):45-53
PubMed   |  Link to Article
Harold D, Abraham R, Hollingworth P,  et al.  Genome-wide association study identifies variants at CLU and PICALM associated with Alzheimer's disease.  Nat Genet. 2009;41(10):1088-1093
PubMed   |  Link to Article
Lambert JC, Heath S, Even G,  et al; European Alzheimer's Disease Initiative Investigators.  Genome-wide association study identifies variants at CLU and CR1 associated with Alzheimer's disease.  Nat Genet. 2009;41(10):1094-1099
PubMed   |  Link to Article
Albers JJ, Tollefson JH, Wolfbauer G, Albright RE Jr. Cholesteryl ester transfer protein in human brain.  Int J Clin Lab Res. 1992;21(3):264-266
PubMed   |  Link to Article
Yamada T, Kawata M, Arai H, Fukasawa M, Inoue K, Sato T. Astroglial localization of cholesteryl ester transfer protein in normal and Alzheimer's disease brain tissues.  Acta Neuropathol. 1995;90(6):633-636
PubMed   |  Link to Article

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