0022-3565/03/3063-821–827$7.

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THE JOURNAL OF PHARMACOLOGY AND EXPERIMENTAL THERAPEUTICS Vol. 306, No. 3
Copyright © 2003 by The American Society for Pharmacology and Experimental Therapeutics 41616/1087470
JPET 306:821–827, 2003 Printed in U.S.A.

Perspectives in Pharmacology

The Cholinergic Hypothesis of Age and Alzheimer’s Disease-

Related Cognitive Deficits: Recent Challenges and Their
Implications for Novel Drug Development

A. V. TERRY JR. and J. J. BUCCAFUSCO

Program in Clinical and Experimental Therapeutics, University of Georgia College of Pharmacy (Augusta Campus) (A.V.T.), Small Animal

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Behavior Core (A.V.T.), and Alzheimer’s Research Center and Department of Pharmacology and Toxicology (A.V.T., J.J.B.), Medical College of
Georgia, Augusta, Georgia; and Department of Veterans Affairs Medical Center, Augusta, Georgia (A.V.T., J.J.B.)

ABSTRACT
The cholinergic hypothesis was initially presented over 20 years taken in perspective and evaluated within the wide range of
ago and suggests that a dysfunction of acetylcholine contain- cholinergic abnormalities known to exist in both aging and AD.
ing neurons in the brain contributes substantially to the cogni- The results of both post mortem and antemortem studies in
tive decline observed in those with advanced age and Alzhei- aged humans and AD patients, as well as animal experiments
mer’s disease (AD). This premise has since served as the basis suggest that a host of cholinergic abnormalities including alter-
for the majority of treatment strategies and drug development ations in choline transport, acetylcholine release, nicotinic and
approaches for AD to date. Recent studies of the brains of muscarinic receptor expression, neurotrophin support, and
patients who had mild cognitive impairment or early stage AD in perhaps axonal transport may all contribute to cognitive abnor-
which choline acetyltransferase and/or acetylcholinesterase malities in aging and AD. Cholinergic abnormalities may also
activity was unaffected (or even up-regulated) have, however, contribute to noncognitive behavioral abnormalities as well as
led some to challenge the validity of the hypothesis as well as the deposition of toxic neuritic plaques in AD. Therefore, cho-
the rationale for using cholinomimetics to treat the disorder, linergic-based strategies will likely remain valid as one ap-
particularly in the earlier stages. These challenges, primarily proach to rational drug development for the treatment of AD
based on assays of post mortem enzyme activity, should be other forms of dementia.

The Cholinergic Hypothesis For more than 20 years, studies of the brains of those with
advanced age and Alzheimer’s disease (AD) have consistently
A variety of studies in humans indicate that basal forebrain
found damage or abnormalities in these pathways (particularly
and rostral forebrain cholinergic pathways including converg-
basal forebrain projections) that appeared to correlate well with
ing projections to the thalamus serve important functional roles
the level of cognitive decline. As a result, the so-called “cholin-
in conscious awareness, attention, working memory, and a
ergic hypothesis” was developed, which essentially states that a
number of additional mnemonic processes (Perry et al., 1999).
loss of cholinergic function in the central nervous system con-
tributes significantly to the cognitive decline associated with
The authors of this work are supported by the National Institute of Mental advanced age and AD (reviewed, Bartus, 2000). Extensive lit-
Health, The Alzheimer’s Association, The Institute for the Study of Aging, and erature from animal experiments supports the human data
the Office of Research and Development, Medical Research Service, Depart-
ment of Veterans Affairs. The authors have also provided consultation or
described above. In fact, the importance of cholinergic function
performed research (relevant to this article) either contractually or in collab- in the brain to learning and memory was first recognized more
oration with a number of pharmaceutical companies including Abbott Labo- than 30 years ago after cholinergic antagonists (specifically
ratories, Boehringer Ingelheim, Hoechst Marion Roussel, Janssen Pharmaceu-
tica, Lilly, Merck, Pfizer, Roche Bioscience, SIBIA Neurosciences, Teva antimuscarinic agents) were found to impair memory in rats
Pharmaceuticals, and Wyeth-Ayerst Research. (Deutsch, 1971). Considerable additional evidence now sup-
Article, publication date, and citation information can be found at
http://jpet.aspetjournals.org. ports this early work, and antimuscarinic agents such as sco-
DOI: 10.1124/jpet.102.041616. polamine and atropine have been shown to impair memory

ABBREVIATIONS: AD, Alzheimer’s disease; MCI, mild cognitive impairment; AChE, acetylcholinesterase; ChAT, choline acetyl transferase; NGF,
nerve growth factor; PET, positron emission tomography; APP, amyloid precursor protein; A␤, amyloid-␤.

821
822 Terry and Buccafusco

performance in a variety of behavioral paradigms in rodents. transferase (ChAT) was not reduced in post mortem neocor-
Such tests include passive (inhibitory) avoidance procedures, tical tissues of those recently diagnosed with mild AD. As a
operant (matching and nonmatching) tasks, and spatial learn- result, the authors suggested that: 1) it is unlikely that a
ing (and working memory) procedures such as water maze and cholinergic marker could be used as an early indicator of AD;
radial arm maze tasks (reviewed, Decker and McGaugh, 1991). 2) it is unlikely that a cholinergic deficit could be identified
These data have been further extended to include selective prior to the patient becoming symptomatic; and 3) only the
muscarinic (i.e., M1) antagonists such as pirenzepine (Hunter patients with more severe disease should be a target for
and Roberts, 1988) as well as centrally acting nicotinic-cholin- cholinergic treatment. In addition, DeKosky and colleagues
ergic antagonists such as mecamylamine (Levin, 1992). Both (DeKosky et al., 2002) failed to detect any reduction in ChAT
muscarinic antagonists (Terry et al., 1993a; Vitiello et al., 1997) activity in a number of cortical regions studied in patients
and nicotinic antagonists (Elrod and Buccafusco, 1991; New- diagnosed with MCI or mild AD, and in fact, activity was
house et al., 1994) have also been shown to impair memory actually up-regulated in the frontal cortex and hippocampus
performance in monkeys and humans. Furthermore, lesions in of those with MCI. In another study, neurons containing
animals that damage cholinergic input to the neocortex or hip- ChAT and the vesicular acetylcholine transporter protein
pocampus from the basal forebrain (e.g., nucleus basalis mag- were preserved in the nucleus basalis in individuals with
nocellularis and medial septum/diagonal band) disrupt perfor- MCI and early AD (Gilmor et al., 1999). Collectively, the
mance of the same memory tasks that are impaired with articles cited here have led to editorials (e.g., Morris, 2002)
cholinergic blockade (reviewed in Decker and McGaugh, 1991). that have further challenged the assumptions and validity of

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It should be noted that damage to similar basal forebrain re- the cholinergic hypothesis as it applies to AD (particularly in
gions in humans (as a result of arterial aneurysms, or resection the early stages).
of an arteriovenous malformation) has also been associated It should be noted that while the aforementioned studies
with severe memory deficits (Damasio et al., 1985). and subsequent editorials provide valuable data and discus-
As a result of the findings cited above (i.e., in both humans sion, some of the conclusions appear somewhat premature.
and animals), the primary therapeutic approach to date to Since neither ChAT nor AChE are rate-limiting cholinergic
address the cognitive loss associated with AD has been that enzymes, they are unlikely to accurately reflect cholinergic
of a cholinergic replacement strategy. This approach has function in the living patient, and a host of factors that were
been attempted using muscarinic and nicotinic-cholinergic not assessed (or even mentioned in these studies) could be
ligands and acetylcholinesterase inhibitors (reviewed in Buc- compromised in cholinergic neurons before changes in these
cafusco and Terry, 2000). To date, however, only the data enzymes would be observed. Examples from the post mortem
derived from clinical trials with acetylcholinesterase inhibi- AD literature include alterations in high-affinity choline up-
tors (e.g., tacrine, donepezil, rivastigmine, and galantamine) take, impaired acetylcholine release, deficits in the expres-
have provided convincing evidence of an adequate level of sion of nicotinic and muscarinic receptors, and dysfunctional
efficacy and reliability in AD balanced with an acceptable neurotrophin support (reviewed in Auld et al., 2002). Each of
burden of side effects. Accordingly, these agents are the only these important factors deserves further discussion. Alter-
drugs currently approved by the United States for clinical ations in high-affinity choline transport (i.e., the rate-limit-
use in AD. Due to the modest risk of hepatotoxicity associ- ing process for acetylcholine synthesis) have been observed in
ated with tacrine, the latter three compounds listed above post mortem AD brains (Slotkin et al., 1990) as well as in the
are generally preferred. Agents such as the glutamate antag- brains of transgenic mice that exhibit AD-like amyloid pa-
onist memantine have recently been associated with im- thology (Apelt et al., 2002). An increase in choline flux across
provements in advanced AD symptomatology and may sug- the membranes of neuronal cells exposed to ␤-amyloid has
gest one new approach to therapy. also been hypothesized to contribute to the selective vulner-
ability of cholinergic neurons in AD (Allen et al., 1997). The
results of experiments by Kar and colleagues (Kar et al.,
Challenges to the Cholinergic Hypothesis 1998) using rat hippocampal slices indicated that under
Investigations focused on the brains of those with mild acute conditions, amyloid peptides could inhibit the uptake of
cognitive impairment (MCI) or the very early stages of AD choline and decrease endogenous acetylcholine release with-
are becoming increasingly important as diagnostic methods out exhibiting effects on ChAT activity. Interestingly, in ear-
for these conditions become more refined and accurate. Such lier studies, Nilsson and colleagues (Nilsson et al., 1986)
investigations may aid the development and/or identification detected a deficit in potassium evoked acetylcholine release
of neuroprotective strategies as well as more specific disease in post mortem cortical tissue from AD patients. A variety of
management approaches. In most previous studies (that studies have reported reductions in central nicotinic recep-
have attempted to correlate the level of cognitive decline with tors in aged subjects and those who suffered from AD or other
disease neuropathology), the brains of patients with end age-related disease in which dementia was present (e.g.,
stage disease were analyzed and therefore may not be par- Lewy Body disease and Parkinson’s disease; see Perry et al.,
ticularly helpful for new investigative efforts aimed at alter- 2000). In AD, high-affinity ␣4 containing nicotinic receptors
ing disease progression if the disease is diagnosed at a very appear to be more significantly reduced than either ␣3 or ␣7
early stage. The results of the small number of published containing receptors, although decreases in ␣7 binding sites
reports available in which the brains of patients diagnosed have been observed in Lewy Body disease (see review, Pic-
with MCI and/or mild AD were analyzed have led some to ciotto and Zoli, 2002). This finding suggests that nicotinic
begin to challenge the validity of the cholinergic hypothesis. receptor subtypes may be differentially reduced in different
For example, Davis and colleagues (1999) reported that the forms of dementia.
activity of acetylcholinesterase (AChE) and choline acetyl- There is a considerable amount of evidence to suggest that
 The Cholinergic Hypothesis, Challenges, and Drug Development 823
nerve growth factor (NGF) support to cholinergic neurons in deterioration and variability in the data associated with post
the basal forebrain of AD patients is deficient leading to mortem AD brains pose a significant challenge, an issue that
atrophy and possibly cell death. While there does not appear underscores the importance of the development and use of
to be a deficiency in the synthesis or availability of NGF appropriate animal models of AD. As better in vivo imaging
protein in the hippocampus or neocortex in AD brains, sub- methods become more widely available, ambiguities related
stantial evidence suggests that retrograde transport of the to cholinergic function in the central nervous system of living
neurotrophin and signal transduction via the high-affinity patients suffering from MCI or early AD will likely become
tyrosine receptor kinase (TrkA receptor) is compromised (see better elucidated. Interestingly, several in vivo imaging stud-
Mufson, 1999). While not demonstrated specifically in the ies conducted to date in AD patients appear to support the
cholinergic phenotype, deficits in axonal transport in cortical cholinergic hypothesis. For example, PET studies using
neurons have also been reported to occur in AD (Dai et al., [11C]N-methylpiperidin-4-yl-propionate indicate that cortical
2002). This finding highlights a fundamental cellular process acetylcholinesterase activity is indeed reduced in AD pa-
that may be disrupted in many neuronal populations in AD tients (Kuhl et al., 1999). [11C]Nicotine-based PET studies
brains including cholinergic neurons, and further, deficits in indicate that nicotinic receptor deficits are in fact an early
axonal transport could underlie the deficits of retrograde phenomenon in AD, and these reports further suggest that
transport of NGF. It is certainly conceivable that early subtle cortical nicotinic receptor deficits significantly correlate with
deficits in both retrograde and anterograde axonal transport the level of cognitive impairment (Nordberg, 2001). Other
could precede measurable deficits in many cholinergic mark- PET studies employing the nonselective muscarinic ligands

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ers including ChAT or AChE. For a graphic summary of the [123I]quinuclidinyl benzilate and [11C]N-methyl-4-piperidyl
information provided in this section, please refer to Fig. 1. benzilate indicate both age- and AD-related decreases in
An additional issue that is important to address in regard binding in neocortical regions (see Zubieta et al., 2001).
to the recent challenges to the cholinergic hypothesis (as well Moreover, single photon emission computerized tomography
as many of the reports that support the hypothesis) relates to (SPECT) studies using [123I]benzovesamacol binding indi-
the condition of the tissue samples studied. It should not be cate that the vesicular acetylcholine transporter is reduced
understated that the collection of post mortem human tissues throughout the entire cerebral cortex and hippocampus in
for neurochemical analysis involves unavoidable delays that early onset AD patients (Kuhl et al., 1996).
can compromise the viability of the tissues analyzed. While
the studies cited above report impressive post mortem inter-
vals ranging from approximately 4 to 12 h, this contrasts
Aging and Brain Cholinergic Neurons
with animal studies in which post mortem intervals often As age currently represents the most potent of the known
involve a matter of minutes. Therefore, unavoidable tissue risk factors for AD, it seems relevant to ask whether the

Fig. 1. Schematic representation of the known and proposed changes in cholinergic neurons that occur in the aged and early AD brain compared with
healthy young neurons. Alterations in high-affinity choline uptake, impaired acetylcholine release, deficits in the expression of nicotinic and
muscarinic receptors, dysfunctional neurotrophin support (i.e., NGF receptors), and deficits in axonal transport are represented in the early AD
neuron either by a decrease in the number of symbols presented or by reduced color intensity.
824 Terry and Buccafusco

function of central cholinergic neurons is impaired in the antecedent animal studies citing amnestic properties of cen-
aged. Challenges to the cholinergic hypothesis of AD appear trally acting muscarinic receptor antagonists such as atro-
to ignore the body of evidence in support of the relationships pine and scopolamine. If the hypothesis that decrements in
between aging, cholinergic impairment, and cognitive de- the functional integrity of cholinergic neurons underlie (or at
cline. A study of the effect of advanced age on brain cholin- least significantly contribute to) diminished cognitive func-
ergic function began in earnest in the early 1980’s when tion in aged subjects and those with AD is correct, then one
chemical enzymatic methods were developed with the speci- would expect such individuals to be especially sensitive to the
ficity and sensitivity to measure the dynamic aspects of memory-impairing effects of anticholinergic drugs. Indeed,
transmitter function. Methods for the rapid stabilization of substantial data to support this premise have been pub-
brain levels of acetylcholine and choline by rapid freezing or lished. For example, scopolamine evokes significantly more
focused microwave irradiation were also introduced for rou- profound amnestic effects in elderly subjects when compared
tine use. For example, Gibson and coworkers (1981) exam- with younger subjects (Zemishlany and Thorne, 1991; Flicker
ined whole brain synthesis of acetylcholine in aged mice from et al., 1992) and in subjects with AD when compared with
3 to 30 months of age. They reported that the biosynthesis of nondemented elderly subjects (Sunderland et al., 1987).
acetylcholine (measured by injection of a radio-labeled pre- Some years ago we also investigated the issue of age-
cursor) declined by up to 75% in the 30 month-old animals. related sensitivity to anticholinergics and compared the ef-
Mild hypoxia further decreased acetylcholine synthesis by fects of scopolamine and the selective peripherally acting
90%. Moreover, aged cholinergic neurons were more im- muscarinic antagonist glycopyrrolate on a series of cognitive

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paired in their ability to release acetylcholine following po- paradigms administered to healthy elderly (55– 67 years old)
tassium stimulation than they were in their ability to syn- and young (28 – 47 years old) volunteer subjects (Ray et al.,
thesize the transmitter (Gibson and Peterson, 1981). 1992). For each test administered, the results were compared
Subsequent in vivo microdialysis methods largely confirmed directly to those produced by glycopyrrolate. The scopol-
these early findings (e.g., Wu et al., 1988). The concept that amine data are reorganized and reproduced in Fig. 2, A and
aged brain cholinergic neurons function relatively normally B. Glycopyrrolate did not significantly affect baseline test
until stressed has been supported through experiments that scores (data not shown). We also measured drug levels in the
used various methods to increase acetylcholine output subjects and found them to be similar between the two
(Meyer et al., 1986; Gilad et al., 1987; Moore et al., 1996) or groups. As indicated in Fig. 2A, the elderly subjects were
that damage cholinergic neurons (Burk et al., 2002). It seems impaired relative to their younger cohort in their perfor-
reasonable to conclude, therefore, that any sustained insult mance of the selective reminding task, both for the consistent
to forebrain cholinergic neurons could interfere with the abil- long-term retrieval and the delayed versions. In particular,
ity of these cells to provide sufficient transmitter release for elderly subjects exhibited a rapid decline in task performance
normal function. Sarter and his coworkers (Burk et al., 2002) with dose in the delayed version of the task that involved the
tested this possibility directly in a longitudinal series of learning and recall of new words in the selective reminding
experiments in which chemical lesions of basal forebrain task. Elderly subjects also were impaired by the highest dose
cholinergic neurons were created in young rats with the aim of scopolamine on their performance of the paired associates
of producing only limited loss of basal forebrain cholinergic learning task. Younger subjects were not affected by this less
cells. The rats had been previously well trained in the per- cognitively demanding task (associated word pairs are
formance of a sustained attention task. Whereas initially formed during rehearsal). Performance of the symbol digit
there was a similar degree of task performance in both ex- modality task was also impaired in the elderly subjects after
perimental groups, a significant dissociation between le- receiving the highest dose of scopolamine (Fig. 2B). This task
sioned and control rats (in terms of task efficiency) did not requires the subject to use a key to substitute numbers for
occur until the animals reached 31 months of age, when the meaningless geometric designs and requires the efficiency of
lesioned group exhibited significant task impairment. The multiple mechanisms in both hemispheres. As with the sym-
results of these studies in aged rodents become more relevant bol digit modality task, the digit span task was performed
to the topic of this article considering the observation that less efficiently by the elderly cohort at baseline, but unlike
most of the age-related changes pertained specifically to dy- the symbol digit modality task, there was no further decre-
namic aspects of brain cholinergic neurons. In many of the ment with scopolamine. Digit span is a crude measure of
studies cited above and in many other reports, indirect mea- attention or immediate memory. The inability of scopolamine
sures of standard cholinergic markers (as might be deter- to further impact this aspect of cognition was confirmed by
mined from autopsied tissues) often do not show such dra- the lack of effect of the drug in the continuous performance
matic age-related differences. task, which requires sustained vigilance. In the more difficult
CPT-AX version (see Fig. 2B) of the continuous performance
task, the elderly appeared to be more affected by scopol-
Anticholinergic Drugs in Elderly Subjects and amine, but relative to the effects of glycopyrrolate, there were
AD Patients no significant differences between the two groups. Overall,
The body of evidence in support of the role for central results of this study are consistent with the general impair-
cholinergic neurons, particularly nucleus basalis and septo- ment of elderly subjects at baseline on certain cognitive
hippocampal projections, in learning and memory is too vast tasks. They are also consistent with the marked sensitivity to
to discuss here. As indicated previously in this article, how- muscarinic receptor blockade exhibited by the elderly. Sur-
ever, the cholinergic hypothesis pertaining to memory loss in prisingly, tasks of attention and sustained vigilance were
AD was largely derived initially from reports of decreased affected to a much lower degree than were tasks of immedi-
cholinergic markers in post mortem AD brains and several ate recall and delayed recall.
 The Cholinergic Hypothesis, Challenges, and Drug Development 825

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Fig. 2. Effects of intramuscular (i.m.) administration of scopolamine (dose range 2.0 –7.0 ␮g/kg) on performance of a cognitive task battery in 11 elderly
and 8 young (human) subjects. Neuropsychological tests were administered in four post-treatment testing periods that were initiated 90 min after
scopolamine administration. A, SRT, selective reminding test; CLTR, consistent long-term retrieval; PAL, paired associates learning. B, SDMT,
symbol digit modalities test; CPT, continuous performance test. For the CPT, the subject was shown a series of randomly generated letters of the
alphabet. He/she was required to hit the spacebar of the computer whenever an X appeared on the screen, hence CPT-X. A more difficult version
required the subject to hit the spacebar whenever X was preceded by A, hence CPT-AX. ⴱ, significantly different (P ⬍ 0.05) from effect measured after
i.m. administration of 4.4 ␮g/kg glycopyrrolate (ⴱ represents significant post hoc t values determined only for those data sets that exhibited significant
treatment by cohort interactions according to analysis of variance). Each value represents the mean ⫾ S.E.M.

Amyloid and the Cholinergic System agonists also may decrease ␶ protein phosphorylation in vitro
and in vivo (Sadot et al., 1996; Genis et al., 1999), another
Notwithstanding the recent challenges to the cholinergic
potential disease-modifying effect of this class of compounds,
hypothesis cited above, it has been generally promoted that
as hyperphosphorylated ␶ protein is linked to cellular disrup-
basal forebrain cholinergic neurons constitute an early target
tion by neurofibrillary tangles.
for toxicity associated with the disease. Cholinergic neurons
The activation of nicotinic acetylcholine receptors also may
arising from the nucleus basalis and from the medial septum
produce disease-modifying actions in AD. For example, the
appear to be significantly more vulnerable than even the
ability of nicotine to evoke neuroprotective effects has been
nearby neostriatal cholinergic neurons (Jhamandas et al.,
2001). Therefore, theories concerning the proximal cause of demonstrated in both in vitro and in vivo models of neural
AD should account for this selective vulnerability of neurons toxicity (Owman et al., 1989; Kihara et al., 1997). The mech-
comprising basal forebrain cholinergic pathways. Since the anism for nicotine’s neuroprotective actions may involve the
overexpression and deposition of brain amyloid probably drug’s ability to transiently increase intracellular calcium
plays some role in the neurodegeneration associated with with downstream actions to increase the synthesis of various
AD, the relationship between amyloid deposition and cholin- neurotropic factors and their receptors (e.g., Dajas-Bailador
ergic neuron activity is certainly of interest. Interestingly, et al., 2000; Jonnala et al., 2002). In fact, nicotine has been
agonists partially selective for the M1 subtype of the musca- shown to inhibit the development of cellular toxicity induced
rinic-cholinergic receptor have been reported to elevate the by A␤ peptides (see Woodruff-Pak et al., 2002). Clearly, the
nonamyloidogenic amyloid precursor protein (␣-APPs) and degeneration of basal forebrain cholinergic neurons, which
decrease amyloid-␤ (A␤) levels (Muller et al., 1997; Fisher et depend for their viability on continuous neurotrophic influ-
al., 2002). This effect on APP processing appears to occur via ence, could lead to both a cycle of decreasing stimuli for
the ability of these drugs to use downstream signaling path- factors associated with cell survival and for emphasis of the
ways that involve the activation of protein kinase C and production of neurotoxic forms of A␤ peptides. These charac-
mitogen-activated protein kinase (Haring et al., 1998). M1 teristics of basal forebrain cholinergic neurons fail to provide
826 Terry and Buccafusco

an explanation as to their selective vulnerability to the dis- ory enhancement may have a wider application than merely
ease process. Nevertheless, it has been shown that ␣7 nico- the conditions (described above) in which cholinergic function
tinic acetylcholine receptors can serve as high-affinity bind- is (significantly) impaired. Schizophrenia and other disorders
ing sites for A␤ peptides (Wang et al., 2000). Moreover, A␤ in which cognitive dysfunction and distractibility are ob-
peptides can block the functional interaction of nicotinic ago- served (e.g., attention deficit hyperactivity disorder) offer
nists with their receptors on hippocampal neurons (Liu et al., just a couple of examples. Currently, several cholinergic-
2001). The potential blockade of basal forebrain and hip- based treatment strategies are in fact being pursued in the
pocampal nicotinic receptors by endogenous A␤ peptides has early phases of clinical trials for treatment of the cognitive
implications not only for the cognitive decline associated with deficits associated with schizophrenia.
early stages of the disease process but also suggests a mech-
anism for the targeting of the AD-related toxic peptides to Concluding Remarks
neural cells expressing ␣7 nicotinic receptors.
Thus, failure of the dynamics of cholinergic neurotransmis- One of the greatest challenges to the elucidation of AD
sion that is associated with aging and with early stages of AD etiology is the difficulty in studying the earliest changes in
could contribute to a cycle of neurotoxicity in advance of any neuronal function in the brain and correlating these changes
detectable change in standard cholinergic marker enzymes or with ante mortem cognitive and behavioral function. Al-
even before the deposition of amyloid plaques (Selkoe, 2002; though suitable tissue specimens from patients with MCI
Woodruff-Pak et al., 2002). This possibility is suggested by and early AD are difficult to obtain, they currently represent
the most logical pathway to understanding the most proxi-

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the finding that in certain transgenic strains of mice that
overexpress mutated human APP, cognitive decline occurs in mal causes of the disease process. The small numbers of
advance of the deposition of significant amounts of amyloid studies that have been conducted to date to analyze tissues
material (Holcomb et al., 1999; Kotilinek et al., 2002). from patients who had MCI or early AD have certainly cre-
ated a number of new questions related to the cholinergic
hypothesis that may only be adequately addressed after in
Cholinergic-Based Therapeutic Strategies vivo imaging techniques become more reliable and widely
(Present and Future Considerations) available to study neurotransmitter systems in the brains of
The preceding paragraphs summarize data that strongly sup- living patients. While it is no doubt quite interesting to know
port the assertion that the use of cholinergic agents remains that the marked loss of cholinergic enzymes in relevant brain
valid as one strategy to combat the cognitive and neurodegen- regions well known to occur in late stage AD are not apparent
erative changes of AD. It is also important to note that changes in early stage AD, the finding is perhaps not that surprising.
in the central cholinergic system in AD may also contribute to a From the above discussion it is evident that there probably
variety of adverse behavioral symptoms (i.e., in addition to exists ongoing targeted neural insults during aging and in
cognitive deficits) such as depression, aggressive behavior, psy- the earliest stages of AD that affect the dynamics of cholin-
chosis, and overactivity (Minger et al., 2000). These so called ergic function without the marked loss of these enzymes.
“noncognitive” symptoms of AD increase caregiver burden, sig- Indeed, the anatomically selective up-regulation of ChAT
nificantly raise the direct costs of care, and result in earlier activity in autopsied brain tissues derived from subjects with
institutionalization (reviewed Eustace et al., 2002). A number of mild cognitive impairment (DeKosky et al., 2002) may rep-
studies now indicate that the standard therapy for cognitive resent an attempt by cholinergic neurons under stress to
dysfunction in AD (i.e., the acetylcholinesterase inhibitors) are compensate for functional impairments in transmitter re-
associated with improvement in a number of behavioral symp- lease. Accordingly, there remains a host of rational drug
toms including depression, psychosis, agitation, and a delay in development approaches related to central cholinergic neu-
nursing home placement (reviewed, Cummings, 2003). Such ronal function in memory disorders that may indeed pay
findings provide an additional rationale for the use of cholin- further dividends in the future. Such approaches involve the
ergic-based therapies in AD. development of novel and selective cholinesterase inhibitors
Cholinergic abnormalities (which correlate with the degree of (with more innocuous side effect profiles) muscarinic and
memory decline) have also been observed in association with neu- nicotinic-cholinergic ligands, and methods to enhance growth
rodegenerative conditions other than AD such as Parkinson’s factor (NGF) support to central cholinergic neurons. Such
disease, dementia with Lewy bodies (reviewed, Perry et al., therapies may not only afford cognitive improvements and
1999), and most recently, vascular dementia (reviewed, the amelioration of adverse behavioral symptoms in AD but
Grantham and Geerts, 2002). Accordingly, the use of acetylcho- also may provide neuroprotective and neurotrophic actions
linesterase inhibitors has to a limited extent been studied in that could be beneficial in several forms of dementia as well
these patient populations. To date, rivastigmine has been ob- as other debilitating conditions such as schizophrenia.
served to benefit patients suffering from dementia with Lewy
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