Loss of brain tissue — atrophy of the brain substance – leads to a progressive shrinkage of the brain as the disease advances. Viewed externally, the brain therefore looks smaller and the spaces or sulci between the ridges, gyri, become bigger. Internally, the hollow spaces within the brain enlarge; the brain from a person with Alzheimer’s disease weighs less than normal. The degree of wasting is most marked in younger patients; in many older people with the disease the brain can appear very similar to that of a non-demented elderly person. The shape and degree of wasting of the brain can be seen on modern brain scans.
Although there is no particular diagnostic feature of Alzheimer’s disease when the brain changes are observed in this way, the absence of any other abnormality, a cerebral tumour or stroke-damage for example, makes the diagnosis of Alzheimer’s disease more likely. The similarity, however, between the degree of brain wasting in normal old people and elderly subjects with Alzheimer’s makes this observation of less value than in younger people, for whom any significant degree of atrophy is quite clearly abnormal. The most marked loss of brain substance usually occurs in the temporal lobes, particularly in the structure known as the hippocampus. As this part of the brain is particularly important for memory function, this fits in well with our knowledge that memory loss is one of the major symptoms of the disease.
At a microscopic level there are two main changes, both of which have already been briefly mentioned. One of these is the formation of disc-like plaques of abnormal tissue, found especially in the grey matter of the cortex; the other is the collection inside nerve cells of bundles of an abnormal fibril-like substance, called neurofibrillary tangles. Both of these occur to a lesser extent in the normal ageing brain. In Alzheimer’s disease the changes are more widespread and greater in number.
Further changes that are found in the brain of a person suffering from Alzheimer’s disease include abnormalities within the cells and the formation, within the walls of some of the small blood vessels, of an abnormal substance called amyloid. This amyloid is very similar to the material that is found in the centre of the plaques. It is found in significant amounts in many cases of Alzheimer’s disease and is also sometimes discovered in apparently normal, older people.
Amyloid is found in other parts of the body in other medical conditions. Some researchers have looked for a connection between the amyloid of other conditions and that of Alzheimer’s disease. The amyloid of Alzheimer’s is very different to that found in, say, the liver or the heart in other unrelated illnesses. At the moment it seems unlikely that there is any specific link.
The abnormalities that affect the brain cells would seem to lead to the death of many of them. Therefore when the cerebral cortex is examined under the microscope it becomes apparent that there are, in many areas, fewer cells than there should be and that a significant proportion of those that remain are affected by abnormal changes such as neurofibrillary tangle formation. In addition, some of the supporting glial cells increase in number. The general pattern of these changes, however, varies considerably from case to case and the largest number of nerve cells appears to be lost from the temporal lobe and the hippocampus. The actual degree of cell loss is still a matter of dispute because measurement of cell numbers in the brain is technically very difficult. It is, however, generally agreed that the greatest cell loss occurs in younger subjects.
There are also changes in the pattern and extent of branching of the nerve fibres in the brain. Although these are difficult to understand, they are probably one of the more important changes as nerve cells interact with each other via the connections, or synapses, made between their nerve fibres and the nerve fibres of other cells. The disruption of this system of communication leads to neurological disorders.
The plaques, commonly called senile plaques, and neurofibrillary tangles are the best-researched of the abnormalities and probably the most important.
Senile Plaque
Senile plaque can be shown to consist of granular material in the centre of which is a substance loosely referred to as the core. The granular material on the rim of the plaque consists largely of nerve cell fibres, their contents, and a collection of glial cell fibres. In other words, this rim consists largely of components that are normally part of brain cells. The centre of the plaque is made out of amyloid, now known to be similar to the amyloid protein found in some of the blood vessels.
These plaques multiply in the cerebral cortex in normal people as they age and are occasionally discerned in the brains of intellectually normal people in their thirties and forties. More usually, however, they begin to build up from the age of fifty. In a person with Alzheimer’s disease they are present in considerably increased numbers and in some cases it is difficult to find an area where you can see the normal structure of the cortex because there are so many plaques crowded into the grey matter. Although they look like flat structures, this is because they are normally observed in cross-section. In fact, they are spherical or oval and seeing them on a microscope slide is rather like taking a hard-boiled egg, cutting a thin slice out of it, laying it down, and looking at it. The yolk would be the equivalent of the amyloid core and the white around it the equivalent of the granular rim of the plaque.
In Alzheimer’s disease these plaques particularly affect those parts of the brain that are associated with memory function. They spread to involve heavily all the grey matter, but not the white matter — that part of the brain that is predominantly made up of nerve fibres.
It seems very much as if the plaques are composed of nerve cells that have begun to degenerate, glial cells that may have been attracted towards the degenerating nerve cell structures, and the amyloid substance in the centre. How they are formed is a matter of conjecture. One theory is that the protein that makes up the amyloid core leaks out of damaged blood vessels; another is that abnormal processes within nerve cells lead to the death of some of their branches and that this somehow leads to the formation of plaques.
Neurofibrillary Tangles
Neurofibrillary tangles occur inside brain cells, particularly the larger neurones. Again, they are especially seen in those parts of the brain that are involved in memory function and like plaques are present in small numbers, in circumscribed areas of the brain, in people who are old but intellectually normal. Eventually the cells containing them die and all one can see is the neurofibrillary tangle material lying free in the brain substance – usually cortical grey matter. Each of these tangles is made up of many smaller filaments arranged in a helix or spiral. They are mainly situated in the cell body, but may extend into some of the nerve cell processes.
Many people feel that neurofibrillary tangles are a better indicator of the presence of Alzheimer’s disease than are plaques. The number of tangles, rather like the number of plaques, relates well to the severity of the dementia; people with more severe Alzheimer’s disease usually have greater numbers of both.
The cause of neurofibrillary tangle formation is, like so many aspects of Alzheimer’s disease, still a matter of speculation. It has been thought that aluminium may be responsible, but for reasons discussed in a later chapter this seems unlikely. It may be that there is a genetic cause or that some infectious agent is responsible. At the moment we really don’t know, but a better understanding of the processes that lead to the formation of tangles may well help us in the fight against the disease.
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