Amyloid-β levels and cognitive trajectories in non-demented pTau181-positive subjects without amyloidopathy

Phosphorylated Tau181 (pTau181) in CSF and recently in plasma has been associated with Alzheimer’s disease. In the absence of amyloidopathy, individuals with increased total Tau levels and/or temporal lobe atrophy experience no or only mild cognitive decline compared with biomarker-negative controls, leading to the proposal to categorize this constellation as suspected non-Alzheimer's disease pathophysiology (SNAP). We investigated whether the characteristics of SNAP also applied to individuals with increased CSF-pTau181 without amyloidopathy. In this long-term observational study, 285 non-demented individuals, including 76 individuals with subjective cognitive impairment and 209 individuals with mild cognitive impairment, were classified based on their CSF levels of pTau181 (T), total Tau (N), amyloid-β(42) (Aβ(42)) and Aβ(42)/Aβ(40) ratio (A) into A+T+N±, A+T–N±, A–T+N±, and A–T–N–. The longitudinal analysis included 154 subjects with a follow-up of more than 12 months who were followed to a median of 4.6 years (interquartile range = 4.3 years). We employed linear mixed models on psychometric tests and region of interest analysis of structural MRI data. Cognitive decline and hippocampal atrophy rate were significantly higher in A+T+N± compared to A–T+N±, whereas there was no difference between A–T+N± and A–T–N–. Furthermore, there was no significant difference between A–T+N± and controls in dementia risk [hazard ratio 0.3, 95% confidence interval (0.1, 1.9)]. However, A–T+N± and A–T–N– could be distinguished based on their Aβ(42) and Aβ(40) levels. Both Aβ(40) and Aβ(42) levels were significantly increased in A–T+N± compared to controls. Long term follow-up of A–T+N± individuals revealed no evidence that this biomarker constellation was associated with dementia or more severe hippocampal atrophy rates compared to controls. However, because of the positive association of pTau181 with Aβ in the A–T+N± group, a link to the pathophysiology of Alzheimer’s disease cannot be excluded in this case. We propose to refer to these individuals in the SNAP group as ‘pTau and Aβ surge with subtle deterioration’ (PASSED). The investigation of the circumstances of simultaneous elevation of pTau and Aβ might provide a deeper insight into the process under which Aβ becomes pathological.