1 Journal of Alzheimer’s Disease xx (20xx) x–xx DOI 10.3233/JAD-190913 IOS Press 5 6 7 8 9 10 11 12 f oo 4 Pr 3 Alby Eliasa,b , Tia Cumminsa,c , Fiona Lamba , Regan Tyrrella , Vincent Dored , Rob Williamsc , Jeffrey V. Rosenfelde,f , Malcolm Hopwoodb , Victor L. Villemagnea and Christopher C. Rowea,∗ a Department of Molecular Imaging and Therapy, Austin Health, The University of Melbourne, VIC, Australia of Psychiatry, The University of Melbourne, VIC, Australia c Florey Institute of Neuroscience and Mental Health, VIC, Australia d Commonwealth Scientific and Industrial Research Organization (CSIRO), Australia e Department of Surgery, Monash University, VIC, Australia f Department of Neurosurgery, Alfred Hospital, Melbourne, VIC, Australia b Department or 2 Amyloid-␤, Tau, and 18 F-Fluorodeoxyglucose Positron Emission Tomography in Posttraumatic Stress Disorder uth 1 14 15 16 17 18 19 20 21 22 23 24 Abstract. Background: Epidemiological studies suggest a relationship between posttraumatic stress disorder (PTSD) and dementia. Objective: This study assessed whether Alzheimer’s disease (AD) imaging biomarkers were elevated in Vietnam veterans with PTSD. Methods: The study compared cognition, amyloid-␤, tau, regional brain metabolism and volumes, and the effect of APOE in 83 veterans with and without PTSD defined by the Clinician’s Administered PTSD Scale. Results: The PTSD group had significantly lower education, predicted premorbid IQ, total intracranial volume, and Montreal Cognitive Assessment score compared with the controls. There was no difference between the two groups in the imaging or genetic biomarkers for AD. Conclusion: Our findings do not support an association between AD pathology and PTSD of up to 50 years duration. Measures to assess cognitive reserve, a factor that may delay the onset of dementia, were lower in the PTSD group compared with the controls and this may account for the previously observed higher incidence of dementia with PTSD. rre cte 13 dA Accepted 15 October 2019 Keywords: Alzheimer’s disease, amyloid, biomarkers, dementia, positron emission tomography, posttraumatic stress disorder, tau 27 INTRODUCTION 29 30 Un 28 co 26 25 Posttraumatic stress disorder (PTSD) is a chronic and disabling condition with a lifetime prevalence of 1–9% in the general population and an increased ∗ Correspondence to: Alby Elias, 145 Studley St, Heidelberg, VIC, Australia. Tel.: +61 417325223; E-mail: alby.elias@ unimelb.edu.au. prevalence in military veterans [1, 2]. Previous studies that provided compelling evidence for cognitive impairment in combat-related PTSD sparked a series of investigations that examined the association between PTSD and dementia in Vietnam veterans [3, 4]. Several epidemiological studies have recently demonstrated an increased incidence of dementia including Alzheimer’s disease (AD) on clinical criteria in older veterans with PTSD com- ISSN 1387-2877/19/$35.00 © 2019 – IOS Press and the authors. All rights reserved 31 32 33 34 35 36 37 38 39 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 f 47 oo 46 Pr 45 METHODS Participant recruitment or 44 The institutional review board of Austin Health, one of the major metropolitan hospitals in Melbourne, provided ethics approval and written informed consent was obtained from all participants. Participants were Australian male Vietnam veterans recruited from the community via advertisement. Interested veterans went through preliminary screening. We applied the following exclusion criteria: substance abuse in the past six months, traumatic brain injury, psychosis, bipolar affective disorder, dementia, existing diagnosis of mild cognitive impairment (MCI), and any unstable medical condition that could have made participation difficult or have a significant impact on cognitive assessment. MCI and dementia were excluded to reduce recruitment bias and avoid confounding of the diagnosis of PTSD. Veterans who passed the initial screening had a face-to-face evaluation with a psychiatrist. uth 43 [23]. Whether tau accumulation or other types of neurodegeneration explain the elevated incidence of dementia in PTSD remains unknown. The aim of this study was to use 18 F-florbetaben and 18 F-AV-1451 to quantify A␤ and tau burden, respectively, 18 F-FDG to estimate regional brain metabolism, and MRI to measure regional brain volume in Vietnam veterans with and without PTSD. Our hypothesis is that veterans with PTSD have increased AD pathology as detected by neuroimaging biomarkers for AD, and neurodegeneration prior to a diagnosis of mild cognitive impairment or dementia. rre cte 42 pared with those without PTSD [5–9]. Furthermore, structural and functional magnetic resonance imaging (MRI) studies have shown reduced volumes of structures involved in cognition such as hippocampi, amygdala, and anterior cingulate cortex along with reduced activity in the anterior cingulate cortex in PTSD [10, 11]. Metabolic imaging studies with 18 Ffluorodeoxyglucose positron emission tomography (FDG PET) have produced inconsistent findings in PTSD with a tendency to hypometabolism in anterior cingulate, limbic, and temporal regions [12]. These studies had small, middle aged cohorts. In contrast, more specific patterns of brain hypometabolism occur in most dementia syndromes [13]. Brain hypometabolism reflects synaptic dysfunction and loss and is regarded as a measure of neurodegeneration that may precede the onset of symptoms by several years [14, 15]. The hypometabolic findings characteristic of AD relate to posterior brain regions, in particular the posterior cingulate gyrus and parietotemporal cortex. The previous studies did not examine the specific pathological biomarkers of AD, amyloid-␤ (A␤) and tau, in PTSD. Deposition of extracellular neuritic plaques and intracellular neurofibrillary tangles is the pathological hallmark of AD [16]. Enabling in vivo and early detection of A␤ and tau using specific radioactive ligands, amyloid and tau PET represents a breakthrough in AD research. The uptake of these radioactive tracers is a proxy measure of A␤ and tau although not the same as the autopsy, which is the gold standard for AD diagnosis. A␤ plaques can be detected on PET up to 20 years before the onset of dementia due to AD [17, 18]. Compared with A␤ plaques, the progression of neurofibrillary tangles is believed to occur closer to the development of symptoms and consequently has shown a better correlation with neuronal damage and cognitive deterioration in patients with AD [19]. Current knowledge of the role of A␤ and tau in the pathogenesis of AD, although not fully understood, is expanding and the relationship may be best described as synergistic [20]. Animal studies have observed elevated A␤ in PTSD [21]. Exposure to psychological trauma and corticotrophin-releasing factor have been reported to enhance both A␤ plaque formation and tau phosphorylation [22]. A recent study by the Alzheimer’s Disease Neuroimaging Initiative (ADNI) group in Vietnam veterans (ADNI-DOD study) did not find an increased risk of AD with PTSD according to the global A␤ burden estimated from 18 F-florbetapir PET co 41 Un 40 A. Elias et al. / Amyloid-␤, Tau, and 18 F-Fluorodeoxyglucose Positron Emission Tomography dA 2 Brain imaging All participants underwent 20-min PET scans acquired 90 min after a slow IV bolus administration of 250 MBq (±10%) of 18 F-florbetaben and 70 min after the injection of 370 MBq of 18 F-AV-1451. Scans were acquired on a Siemens PET/CT mCT128 and CT attenuation correction was applied. Image reconstruction used the Ordered Subset Expected Maximization algorithm. There was no correction for partial volume effect. We analyzed the PET scans with the Computational Analysis of PET from AIBL and calculated standardized uptake value ratio (SUVR) of 18 F-florbetaben using cerebellar grey matter uptake as the reference to quantify global A␤ burden [24]. Amyloid burden was also calculated in 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 A. Elias et al. / Amyloid-␤, Tau, and 18 F-Fluorodeoxyglucose Positron Emission Tomography 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 Clinical and cognitive assessment f 147 oo 146 We used Clinician’s Administered PTSD Scale (CAPS) - DSM-IV version to assess PTSD [26]. A score of 40 or more and a history of combat exposure constituted the inclusion criteria for the PTSD group. This score was based on the existing diagnostic utility data for a range of selected cut-off scores which indicated that a CAPS score of 40 had 93% sensitivity and 80% specificity for dichotomous classification of PTSD [27]. A CAPS score of 30 or less and military experience formed the inclusion criteria for the control group. We have chosen these scores to ensure a clear separation between the diagnostic groups and controls. Subjects who scored between 30 and 40 were excluded from the analysis based on the presumption that they had fluctuating and sub-threshold symptoms. The Geriatric Depression Scale (GDS) measured depressive symptoms [28]. Participants underwent APOE ␧4 genotyping. A vascular risk factor score was calculated by giving one point to each of the following: hypertension, ischemic heart disease, previous history of stroke, atrial fibrillation, current smoking, diabetes mellitus, body mass index over 30, and hypercholesterolemia. Sum of all points gave cumulative vascular risk score. Veterans with mild, moderate, or severe traumatic brain injury according to the criteria set by the U.S Department of Defense (DoD) were excluded. A standardized neuropsychological test battery assessed cognitive functions [29–35]. The following tests measured memory component: the delayed paragraph recall from the Logical Memory Test II, Rey Auditory Verbal Learning Test 30-min delay, and the Rey-Osterrieth complex figure test (ROCFT) 30-min delay. We calculated a composite memory score from these three tests using standard deviation and mean scores from the control population. We used Trail Making Test part A to assess the visual orientation and processing speed, part B to measure executive function, Wechsler Adult Intelligence Scale to measure attention, categorical fluency test to assess semantic fluency, and ROCFT to assess visuospatial orientation and constructional skills. The Mini-Mental State Examination and the Montreal Cognitive Assessment Pr 145 or 144 uth 143 dA 142 and cortical thickness were then estimated using a software Computational Quantification program [24]. The Harmonized Hippocampus protocol was used to define the hippocampus region of interest. Volumetry was adjusted for the TICV by dividing the regional volume by TICV. rre cte 141 Centiloid units using the standard Centiloid method cortical region of interest normalized to whole cerebellum as previously described [25]. 18 Florbetaben scan was read visually by three readers and the classification into negative or positive scan was based on majority results. The visual inspection was based on brain amyloid plaque load, which was derived from the regional cortical tracer uptake in the four regions: lateral temporal cortex, frontal cortex, posterior cingulate cortex/precuneus, and parietal cortex. Typical transverse PET slices were judged as negative if the tracer uptake in the grey matter was lower than that of the white matter and positive if the uptake in the grey matter was equal to or more than that in the white matter. The SUVR of 18 F-AV-1451, using cerebellar grey matter uptake as the reference region, estimated global and regional tau deposition. We measured tau in the following regions: mesial temporal; temporoparietal; and rest of the neocortex. A part of the data analyzed in the preparation of this article were obtained from the ADNI database (http://adni.Ioni.usc.edu). The primary goal of ADNI has been to test whether serial MRI, PET, other biological markers and clinical and neuropsychological assessment can be combined to measure the progression of MCI and early AD. For up-to-date information, see http://www.adni.info.org. For the acquisition of 18 F-FDG PET scan, participants fasted for four hours and then had an injection of 200 MBq of 18 F-FDG. As per standard practice, they remained in a quiet, darkened room for 30 min with eyes open in order to keep the occipital metabolism consistent. Acquisition was commenced 30 min after the injection on a Philips Allegro PET camera. A post-injection transmission scan for attenuation correction was performed. Acquisition time was 20 min. Reconstruction was performed with a RAMLA filter. SUVR was calculated for frontal, mesial temporal, and rest of the neocortex. Participants underwent 3-Tesla Siemens Trio brain MRI for the measurement of hippocampal volume and total intracranial volume (TICV). A three-dimensional (3D) T1 magnetization-prepared rapid gradient echo (MPRAGE) was acquired with the following parameters: FoV = 260 × 256, Matrix = 240 × 256, 160 slices, 1.0 × 1.0 × 1.2 mm voxels, TR = 2300 ms, TE = 2.98 ms, flip angle = 9◦ . The T1 weighted images were rigidly registered to the Montreal Neurological Institute (MNI) average brain and segmented into grey and white matter and cerebrospinal fluid space with Expectation Maximisation Segmentation algorithm. Partial tissue classification co 140 Un 139 3 191 192 193 194 195 196 197 198 199 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 220 221 222 223 224 225 226 227 228 229 230 231 232 233 234 235 236 237 238 239 240 A. Elias et al. / Amyloid-␤, Tau, and 18 F-Fluorodeoxyglucose Positron Emission Tomography 246 247 248 249 277 RESULTS 255 256 257 258 259 260 261 262 263 264 265 266 267 268 269 270 271 272 273 274 275 278 279 280 281 282 283 284 285 286 287 288 co 254 From 2014 March to May 2017, 169 male Vietnam veterans expressed interest in the study. 20 veterans later withdrew from the study for reasons of inconvenience and perceived distress. After excluding 66 veterans (including three veterans who had CAPS score between 30 and 40) for the reasons shown in Fig. 1, we collected the neuropsychological and PET data from the remaining 83 veterans. A diagnosis of lifetime PTSD was present in 53 veterans, and 30 veterans were controls. Among veterans with lifetime PTSD, a diagnosis of current PTSD was present in Un 253 PET imaging There was no significant difference between the PTSD group and the controls in the mean SUVR of the A␤ tracer, 18 F-florbetaben (p = 0.927, Cohen’s d = 0.02). According to the visual inspection of 18 Fflorbetaben scans, 7 (21.8%) veterans with current PTSD and 4 (10.5%) veterans without PTSD had a positive scan. This difference was not significant (χ2 = 0.57, p = 0.48). In the multivariable regression analysis with 18 F-florbetaben SUVR as the dependent variable and current PTSD, age, APOE ␧4, and vascular risk factors as the independent variables, current PTSD did not predict 18 F-florbetaben SUVR (standardized coefficient ␤ = –0.093, p = 0.513), whereas APOE ␧4 did (R2 = 0.126, standardized coefficient ␤ = 0.185, p = 0.043). The regional and global uptake of the tau tracer, 18 F-AV-1451 did not differ between the PTSD and control groups (Table 3). 18 F-AV1451 SUVR did not correlate with any cognitive score. There was no significant correlation between the severity of PTSD as measured by CAPS score and global or regional 18 F-AV-1451 SUVRs. There were no differences in the 18 F-FDG SUVRs between the groups (Table 2). There was no correlation between rre cte 276 The PTSD and the control groups were compared for the following outcome variables: 18 F-florbetaben SUVR and Centiloid units, 18 F-AV-1451 and 18 FFDG SUVRs, MRI regional volumes, and cognitive test scores. Age, APOE ␧4, and vascular risk factors were analyzed as covariates in a multivariable regression analysis because of their known association with amyloid retention. For this study, current PTSD was the explanatory variable for the primary analysis given a priori that it is the persistence of symptoms that is related to the risk of AD in late life. Life-time history of PTSD was also examined. The two-tailed results were corrected for multiple comparisons using the Benjamini-Hochberg procedure. Chi-square (χ2 ) was used to analyze categorical variables, such as positive or negative 18 F-florbetaben scan, and APOE E ␧4 status. Pearson correlation test was performed for the whole sample to test correlation between the tracer SUVRs and CAPS scores. The analyses were performed on SPSS version 21. Using florbetapir A␤ PET results from normal controls in the ADNI study, we calculated that to detect a group difference with an effect size of 0.75, with 80% power at ␣ = 0.05, required 29 subjects in each group. 252 f 245 oo 244 Pr Statistical analysis 243 30. All veterans experienced PTSD symptoms either during or soon after military service. The participants’ characteristics are shown in Table 1. The median current CAPS score for the PTSD group was 52.50 compared with 4 for the control group (Mann-Whitney U = 0.000, p < 0.001). Veterans with current PTSD were slightly younger than those without PTSD (PTSD group mean age: 67.80 ± 2.48 versus the control group mean age: 70.23 ± 5.46; p = 0.043; CI = 0.220–4.64; Cohen’s d = 0.57). Median predicted premorbid IQ (104 versus 114; U = 201.00; p < .001) and years of education (11 versus 12; U = 305.00; p = 0.043) were significantly lower whereas the median GDS score (5.50 versus 1, U = 130.00, p < .001) was significantly higher in the PTSD group than in the controls. The TICV was significantly lower in the PTSD group than in the control group (1565.173 ± 1114.31 cm3 versus 1674.12 ± 1474.64 cm3 ; p = 0.010; CI = 33.59–184.307; Cohen’s d = 0.40). The median vascular risk factor score did not differ significantly between the groups (1 versus 2, U = 384.50, p = 0.318). APOE ␧4 carrier status was available for 55 (92%) participants, and at least one allele was present in 7 (24%) veterans with PTSD and 2 (9%) controls (χ2 = 2.70, p = 0.10). or 251 242 uth 250 (MoCA) measured global cognitive function [36, 37]. Along with the measurement of attention, delayed recall, and visuospatial abilities, MOCA assesses executive function using an alternation task adapted from the Trail Making Test Part B, phonemic fluency task and two-item verbal abstraction task. Wechsler’s Test of Adult Reading (WTAR) estimated premorbid Intelligent Quotient (IQ) [35]. WTAR was adjusted for age and then predicted IQ was calculated using published criteria. 241 dA 4 289 290 291 292 293 294 295 296 297 298 299 300 301 302 303 304 305 306 307 308 309 310 311 312 313 314 315 316 317 318 319 320 321 322 323 324 325 326 327 328 329 330 331 332 333 334 335 336 337 338 A. Elias et al. / Amyloid-␤, Tau, and 18 F-Fluorodeoxyglucose Positron Emission Tomography uth or Pr oo f 5 dA Fig. 1. Participants recruitment. Table 1 Participant characteristics Age Predicted IQ Years of education Total Intracranial Volume (cm3 ) GDS Score 341 342 343 344 345 346 347 348 349 350 351 352 353 354 p (corrected) 70.23 ± 5.46 114 (5) 12.0 (5) 1674.12 ± 1474.64 1 (2) 67.80 ± 2.48 104 (12) 11 (4) 1565.17 ± 1114.31 5.50 (5) 0.043 <0.001 0.043 0.01 <0.001 co 340 Current PTSD (n = 30) Mean ± SD)/Median (Interquartile Range) the severity of PTSD as measured by CAPS and 18 FFDG SUVR in any region. We repeated the analysis for subjects with lifetime PTSD with and without current PTSD (n = 53) against the same control group (n = 30). There was no significant difference in the uptake of any tracer globally or regionally between the two groups. Adding the U.S. ADNI-DOD study amyloid PET data expanded the sample size to a total of 97 Vietnam veterans with PTSD and 85 controls. Centiloid units were calculated to allow the merging of scans obtained with the different A␤ PET tracers, florbetapir and florbetaben. The combined data did not reveal a significant difference between the two groups in the Centiloid values (PTSD Mean: 9.01 ± 20.73; versus Control Mean 14.37 ± 26.12 Cohen’s d = 0.22; Un 339 Controls (n = 30) Mean ± SD/Median (Interquartile Range) rre cte Variables Median rank: 89.85 versus 93.39, p = 0.651; MannWhitney U = 3962.00). More veterans in the control group than in the PTSD group had a positive amyloid scan based on Centiloid score of 25 or more (13 versus 7, χ2 = 7.47, p = 0.024, uncorrected). With the additional ADNI data APOE ␧4 was present in 23 veterans with PTSD and 17 veterans without PTSD (χ2 = 0.567, p = 0.451, uncorrected). MRI results Forty of the lifetime PTSD group including 30 with ongoing or current PTSD, and 25 controls underwent MRI. Others did not have MRI for reasons of inconvenience and metal safety. The TICV was slightly but significantly lower in the current PTSD 355 356 357 358 359 360 361 362 363 364 365 366 367 368 6 A. Elias et al. / Amyloid-β, Tau, and 18 F-Fluorodeoxyglucose Positron Emission Tomography Current PTSD (n = 30) Median/mean (interquartile range) p 1.21 (0.13) 1.16 (0.12) 1.17 (0.11) 1.17 (0.11) 1.13 (0.14) 0.75 ± 0.05 1.05 ± 0.08 1.06 ± 0.07 1.22 (0.16) 1.21 (0.20) 1.16 (0.18) 1.14 (0.16) 1.10 (0.13) 0.74 ± 0.04 1.03 ± 0.05 1.04 ± 0.06 0.610 0.804 0.610 0.610 0.620 0.344 0.384 0.303 18 F-florbetaben 18 F-AV-1451 (mesial temporal) 18 F-AV-1451 (temporoparietal) 18 F-AV-1451 (rest of neocortex) Global 18 F-AV-1451 18 F-fludeoxyglucose (mesial temporal) 18 F-fludeoxyglucose (frontal) 18 F-fludeoxyglucose (rest of neocortex) oo Controls (n = 30) Median/mean (interquartile range) Pr Tracers f Table 2 PET Tracer binding expressed in SUVR Table 3 MRI volumes in PTSD and controls, adjusted for total intracranial volume 0.18 ± 0.01 0.19 ± 0.01 0.08 ± 0.01 0.08 ± 0.01 0.75 ± 0.08 0.69 ± 0.06 0.17 ± 0.02 0.17 ± 0.02 0.33 ± 0.03 0.28 ± 0.04 0.19 ± 0.01 0.19 ± 0.01 0.08 ± 0.01 0.08 ± 0.008 0.72 ± 0.08 0.68 ± 0.07 0.17 ± 0.01 0.17 ± 0.02 0.32 ± 0.04 0.27 ± 0.04 p or Current PTSD (n = 24) uth Left hippocampus Right hippocampus Left amygdala Right amygdala Left middle frontal cortex Right middle frontal cortex Left orbitofrontal cortex Right orbitofrontal cortex Left anterior cingulate cortex Right anterior cingulate cortex Controls (n = 25) Mean dA Variables 0.116 0.131 0.492 0.571 0.332 0.468 0.774 0.660 0.670 0.574 Table 4 Cognitive functions in PTSD and controls Controls (n = 30) Mean ± SD/ Median (interquartile range) Current PTSD (n = 30) Mean ± SD/ Median (interquartile range) p 17.73 ± 3.99 38.97 ± 9.91 37 (15) 90 (42) 29.43 ± 2.97 47.17 ± 10.56 0.02 ± 0.74 29 (1) 28 (4) 15.40 ± 4.10 38.13 ± 11.44 34 (17) 97.50 (65) 30.40 ± 5.99 44.70 ± 9.22 –0.15 ± 0.69 28 (2) 26 (4) 0.135 0.860 0.882 0.182 0.555 0.535 0.535 0.182 0.027 rre cte Variables co Digit Span Categorical fluency Trail making test A (time to completion, s) Trail making test B (time to completion, s) Rey Osterrieth complex figure copy test RAVLT Learning trials Composite Memory score MMSE MoCA 369 370 371 372 373 374 375 376 Un RAVLT, Rey Auditory Verbal Learning Test; MMSE, Mini-Mental State Examination; MoCA, Montreal Cognitive Assessment. group than in the control group (1565.173 ± 1114.31 cm3 versus 1674.12 ± 1474.64 cm3 ; p = 0.01; CI = 33.59–184.307; Cohen’s d = 0.40). There was no significant difference between veterans with and without current PTSD in the adjusted volumes of the hippocampus, amygdala, anterior cingulate cortex, middle frontal, or orbitofrontal cortex on either side (Table 3). The analysis was repeated with sub- jects who had a lifetime diagnosis of PTSD. The TICV was significantly lower in the lifetime PTSD group compared with the control group, but volumetric grey matter measures did not significantly differ between the groups. There was no significant correlation between volumetric measure and severity of current PTSD as quantified by the CAPS score. 377 378 379 380 381 382 383 384 A. Elias et al. / Amyloid-␤, Tau, and 18 F-Fluorodeoxyglucose Positron Emission Tomography 393 394 395 396 397 398 399 400 401 402 403 404 405 406 407 408 409 410 411 412 415 416 417 418 419 420 421 422 423 424 425 426 427 428 429 430 431 432 433 f 392 oo 391 There is abundant literature on cognitive function, structural brain imaging, and incidence of dementia in Vietnam veterans with PTSD, but little is known about the AD pathological biomarkers in PTSD. This study measured A␤ and tau in vivo in Vietnam veterans with PTSD against veterans without PTSD. This ensured a homogenous population with military experience in both groups and an age range in which preclinical AD pathology is developing and detectable in the general population. The present study did not show a significant association between PTSD and increased amyloid deposition in the brain as measured by 18 F-florbetaben. Global amyloid burden or regional amyloid as reflected in the visual inspection was not significantly different between the PTSD and the control groups. Amyloid deposition is the earliest detectable marker of AD and amyloid PET scans become abnormal up to 20 years before the clinical diagnosis of AD dementia [17, 18]. Our co 390 Un 389 Pr DISCUSSION 388 or 414 387 rre cte 413 The performance of both groups was within the normal range of age-adjusted published norms of the neuropsychological tests except on the MoCA where the mean score for the PTSD group (25.27) was fractionally below the conventional cut-off score of 26. In comparison with the controls, veterans with current PTSD scored lower on global cognitive function as measured by the MoCA (Median: 26 versus 28; U = 250.00; p = 0.027). We performed a multivariable regression analysis after log-transformation of the total MoCA score. The predicted premorbid IQ and the GDS score significantly correlated with the total MoCA score and also differed between the groups. Therefore, these variables were included in the model along with current PTSD as explanatory (independent) variables with the MoCA as the dependent variable. The regression analysis met all assumptions. In the regression analysis (adjusted R2 = 0.249), the difference in the performance on the MoCA (␤ = –0.252, p = 0.081) did not retain significance when predicted premorbid IQ (␤ = –0.341, p = 0.009) and depression score (␤ = 0.006; p = 0.611) were adjusted. The cognitive scores are summarized in Table 3. There was no significant difference between the PTSD groups and the controls in the other cognitive measures. The correlation between predicted premorbid IQ and TICV was significant (r = 0.351, p = 0.013). 386 finding is consistent with the results from the USbased ADNI Veterans study that also did not find an association between PTSD and increased A␤ deposition [23]. Like our findings, the PTSD cohort in the ADNI-DOD veterans study had worse global cognition than controls. The ADNI-DOD data revealed a significantly lower level of education in the PTSD group, and our study showed the same. To the best of our knowledge, this is the first study to report tau deposition in PTSD along with A␤, regional brain metabolism and brain volumetry along with neuropsychological data. This is perhaps the most comprehensive assessment of biomarkers of AD in PTSD. We found no increase in binding of the tau tracer 18 F-AV-1451 in PTSD. Similarly, there was no difference between the PTSD group and the controls in regional brain metabolism or regional brain volumetry. If PTSD causes neurodegeneration associated with various dementia syndromes, then it would be likely that after 40 or more years of symptoms in the age group under study, some change would be present. 18 F-FDG PET scan has been reported as showing abnormality several years before the onset of AD dementia [14, 15]. Similarly, alterations in hippocampal and regional cortical volumes in PTSD could be temporary, or the mild volume reductions as previously described may be masked by the atrophy that occurs with normal aging. Our participants were in their 60 s and 70 s, and the effect of aging may have had more impact on volumetric changes than PTSD itself, in cortical as well as hippocampal regions. A longitudinal study is required to address these possibilities. Commensurate with the finding of no difference between PTSD and the control status regarding A␤, tau, and regional brain metabolism and volumes, there was no evidence of an independent association between PTSD and cognitive impairment. Although previous studies, mostly done in younger veterans, have shown impaired cognitive function in PTSD, our findings suggest that cognitive functions are mostly intact in older veterans with PTSD and the mild impairment we found in the global cognitive performance was reflective of predicted premorbid IQ and the affective state. Our finding is in line with previous data that suggested lower premorbid IQ as a vulnerability factor for the development of PTSD upon trauma exposure and associated cognitive impairment [38, 39]. A co-twin-control study of veterans found that premorbid cognitive ability, as measured by Armed Forces Qualification Test, predicted the future risk of PTSD in a dose dependent manner indi- uth Cognitive functions dA 385 7 434 435 436 437 438 439 440 441 442 443 444 445 446 447 448 449 450 451 452 453 454 455 456 457 458 459 460 461 462 463 464 465 466 467 468 469 470 471 472 473 474 475 476 477 478 479 480 481 482 483 484 485 494 495 496 497 498 499 500 501 502 503 504 505 506 507 508 509 510 511 512 513 514 515 516 517 518 519 520 521 522 523 524 525 526 527 528 529 530 531 532 533 534 535 536 537 f 493 oo 492 Pr 491 or 490 uth 489 the previous epidemiological studies may be reflective of this difference. The clinical implication is that treatments that aim to restore physical and cognitive activities in patients with PTSD may increase CR and lead to dementia risk reduction. In this context, reverse causation hypothesis is also valid: i.e., people with higher reserve may more frequently choose to engage in these types of activities. This study has several limitations. We could not access direct measurements of pre-military IQ; premorbid IQ in our study was an indirect measure based on the WTAR. Nonetheless, WTAR was validated and used in the cognitive assessment of traumatic brain injury studies [47]. Secondly, given the negative findings, type II error is an important consideration. Although there were small numbers of veterans with a positive amyloid scan and the samples were underpowered for Chi-square test, the analysis for the global burden of amyloid by SUVR had 80% power to detect a difference with effect size of 0.75 or more. For the amyloid imaging, adding the ADNI data did give improved power sufficient to detect an effect size of 0.43. Another limitation of the study was that large numbers of veterans met the exclusion criteria. Among the excluded veterans some declined participation because of perceived stress. Whether they had more severe PTSD or would have altered the results is unknown. The ADNI-DOD study also reported a large number of excluded veterans. Head injury, substance abuse, and medical illnesses are comorbid with PTSD and such factors may lead to restricted inclusion of veterans. Limited inclusion could impact the generalizability of findings. The literature of CR and BR is complex and still evolving, and an explanation of the relationship between PTSD and dementia, being far from being conclusive, needs more research. In conclusion, our findings indicate that PTSD is not associated with an increased prevalence of the biomarkers for the specific pathology of AD or other forms of progressive neurodegeneration. Compared with the controls, veterans with PTSD had a relatively low cognitive reserve. Given that high cognitive reserve may delay the onset of dementia, low cognitive reserve in PTSD may explain its previous association with dementia. rre cte 488 cating the role premorbid intellectual function in the adaptive coping ability after trauma [39]. It should be noted that patients with PTSD do not form a low IQ group because the premorbid IQ in the PTSD group was consistent with the expected general population average, but the veteran controls were above average. The findings of the present study and those of the ADNI-DOD veterans study do not lend support to a direct link between PTSD and AD pathology. Therefore, it is worth exploring the potential explanatory factors behind the previously reported association between PTSD and dementia including AD [5–9]. The present study suggests a low cognitive reserve (CR) in PTSD. Cognitive reserve is a potential mechanism to buffer the impact of the pathological process associated with AD [40]. With high CR more pathological load is required to produce the same degree of cognitive impairment than with low CR possibly because of recruitment of alternate functional circuits particularly in the dorsolateral prefrontal cortex [41]. High CR affords protection against the onset of dementia, not the neuropathological markers of AD suggesting the role of CR as neurocompensation rather than neuroprotection [42]. According to our findings, predicted premorbid intelligence and education, the proxy measures of CR and TICV which is a measure of brain reserve (BR) were significantly lower in the PTSD group than in the controls. A recent study demonstrated that increased intracranial volume mitigated adverse effects of dementia pathology on cognitive function, particularly attention and executive function [43]. Likewise, premorbid cognitive performance predicted the onset of dementia independent of the potent genetic risk factor for AD, APOE ␧4 [44]. Furthermore, physical and cognitive engagement and leisure activities contribute to CR, but evidence suggests that avoidant behavior and hyperarousal symptoms of PTSD may preclude such activities [45, 46]. We postulate that the relatively low CR and other dementia risk factors associated with PTSD may account for previously observed higher incidence of dementia with PTSD. It may be noted, however, that it is not the abnormally low CR or BR that may explain the association of PTSD and dementia. It is a relative concept in comparison with the controls that is worth considering and the previously reported increased risk of dementia with PTSD was also in comparison with the controls. This may suggest that while subjects with PTSD may have the same risk as that of general population, those without PTSD may have additional protection against the onset of dementia from increased CR or BR and co 487 Un 486 A. Elias et al. / Amyloid-␤, Tau, and 18 F-Fluorodeoxyglucose Positron Emission Tomography dA 8 ACKNOWLEDGMENTS The authors thank the U.S. Department of Defense and Piramal Pharmaceuticals for supporting this 538 539 540 541 542 543 544 545 546 547 548 549 550 551 552 553 554 555 556 557 558 559 560 561 562 563 564 565 566 567 568 569 570 571 572 573 574 575 576 577 578 579 580 581 582 583 584 585 586 A. Elias et al. / Amyloid-␤, Tau, and 18 F-Fluorodeoxyglucose Positron Emission Tomography 596 597 598 599 600 601 602 603 604 605 606 607 608 609 610 611 612 613 614 615 616 617 618 619 620 621 622 623 624 625 626 627 628 629 630 631 632 633 634 635 636 637 638 f 595 [3] [4] [5] [6] [7] oo 594 [2] Pr 593 or 592 639 Eisen SA, Griffith KH, Xian H, Scherrer JF, Fischer ID, Chantarujikapong S, Hunter J, True WR, Lyons MJ, Tsuang MT (2004) Lifetime and 12-month prevalence of psychiatric disorders in 8,169 male Vietnam War era veterans. Mil Med 169, 896-902. 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A complete listing of ADNI investigators can be found at: http://adni.loni.usc.edu/wp-content/uploads/how to apply/ADNI Acknowledgement List.pdf ADNI is funded by the National Institute on Aging, the National Institute of Biomedical Imaging and Bioengineering, and through generous contributions from the following: AbbVie, Alzheimer’s Association; Alzheimer’s Drug Discovery Foundation; Araclon Biotech; BioClinica, Inc.; Biogen; BristolMyers Squibb Company; CereSpir, Inc.; Cogstate; Eisai Inc.; Elan Pharmaceuticals, Inc.; Eli Lilly and Company; EuroImmun; F. 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