Regular paperHypocretin (orexin) loss in Alzheimer's disease
Introduction
Alzheimer's disease (AD) is primarily characterized by cognitive decline. However, sleep disturbances and a disturbed sleep-wake pattern are also a major feature of AD (Samanta et al., 2006). These sleep disturbances are correlated with the severity of dementia (Mirmiran et al., 1992, Witting et al., 1990) and are often the primary reason for institutionalization (Pollak and Perlick, 1991). Up to 82% of AD patients get up during the night (Tractenberg et al., 2003). Other characteristics of the sleep problems of AD patients are excessive daytime sleepiness, napping during daytime, rapid eye movement (REM) sleep dysregulation and circadian rhythm disturbances (Bliwise et al., 1989, Bliwise, 2004, McCurry et al., 1999). These features partly bear a resemblance to the symptoms of narcolepsy.
Narcolepsy is a sleep-wake disorder characterized by excessive daytime sleepiness and cataplexy. Other symptoms are REM sleep dysregulation, resulting in premature transitions to REM sleep, sleep paralysis, and hypnagogic hallucinations (Overeem et al., 2001, Rechtschaffen et al., 1963). The disorder is caused by a general loss of hypocretin (orexin), reflected in undetectable hypocretin-1 cerebrospinal fluid (CSF) levels. The hypocretins are neuropeptides produced only in the lateral hypothalamus by a restricted group of cells that project widely throughout the brain (Peyron et al., 1998). The most densely innervated regions are sleep-wake areas involved in sleep regulation and attention such as the locus coeruleus and raphe nuclei of the brainstem, the cholinergic neurons of the brainstem and forebrain, and histaminergic neurons of the posterior hypothalamus (Fung et al., 2001, Nambu et al., 1999, Peyron et al., 1998, Siegel, 2004, van den Pol, 1999). Hypocretin neurons thus play a vital role in sleep-wake regulation.
AD is a neurodegenerative disorder that affects multiple brain areas and types of neurons, very likely also including the primary sleep-regulating systems. The hypocretin system is affected in various neurodegenerative diseases, such as Parkinson's disease and Huntington's disease (Aziz et al., 2008, Fronczek et al., 2007, Thannickal et al., 2007). We hypothesized that the neurodegenerative process in AD might also affect the hypocretin system, which could contribute to the sleep disturbances of AD patients. The observation of Friedman and others who have shown an inverse relation between lumbar CSF hypocretin-1 concentration and the amount of daytime naps of AD patients supports this possibility (Friedman et al., 2007).
The aim of the current study was to examine whether the hypocretin system is affected in AD. Two approaches were used: the total number of hypocretin-1 producing neurons was determined in the lateral hypothalamus of 10 AD patients and 10 matched controls. Furthermore, the concentration of hypocretin-1 was measured in postmortem ventricular CSF of 24 AD patients and 25 controls (including the patients and controls in which the hypothalamic cell counts were performed).
Section snippets
Postmortem material
Postmortem hypothalami and ventricular CSF were provided by the Netherlands Brain Bank (NBB). Permission was obtained for brain autopsy and for the use of human material and clinical information for research purposes. Ten patients with AD (Braak 5 or 6) and 10 nondemented controls (Braak 0 or 1) were matched for sex, age, postmortem delay (PMD), and fixation time (hypothalamus group). Clinicopathological information of these subjects is shown in Table 1. Ventricular CSF was not available for 2
Hypothalamus group
No significant differences were found in age, sex, postmortem delay, fixation time, brain weight, and clock time of death between AD patients and the control group (all p > 0.079, Table 1).
Hypocretin-1 cytochemistry
The morphology, location, and intensity of staining of hypocretin-1 IR neurons were comparable in AD patients and control subjects (Fig. 2). Hypocretin-1 IR neurons were limited to the perifornical region of the lateral hypothalamus. These neurons began to appear at the level where the fornix reaches the
Discussion
This study shows that the hypocretin system is affected in AD. The number of hypocretin-1 IR neurons was 40% lower in AD patients compared with matched controls. A 14% decrease in hypocretin-1 in ventricular CSF was found in AD patients. The findings that the hypocretin system is affected in AD are in line with a previous study in which the lumbar CSF hypocretin-1 concentration was correlated with a disturbed sleep-wake pattern of AD patients (Friedman et al., 2007).
There was no significant
Disclosure statement
No author has any actual or potential conflicts of interest including any financial, personal or other relationships with other people or organizations within 3 years of beginning this work. Appropriate approval and procedures were used concerning the human material used in the current report.
Acknowledgements
We thank C. Donjacour, R. Balesar, U. Unmehopa, B. Visser, and J. van Heerikhuize for their help in the staining and cell counting procedures.
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No financial support for this study was received.