Memory dysfunction in mild cognitive impairment (MCI) and early Alzheimer disease (AD) dementia is closely associated with synapse loss, and shows significant correlation with pathological tau in synapses and inflammatory glial cell responses in postmortem human brain

Abstract Background Synapse density loss is among the strongest histopathological correlates of dementia in AD. Prodromal stages of AD, comprising amnestic MCI and mild AD dementia, represent the most promising timepoints for interventions aimed at attaining efficacious neurobiological and clinical effects. Yet, the understanding of other contributing neuropathologic changes in these prodromal disease stages and their impact on early cognitive dysfunction remains limited. Methods We studied the visual cortex of 28 demented and non‐demented human brains who had died at Braak III‐IV stages of NFT pathology, and who showed a comparable β‐amyloid plaque burden and absence of NFT deposits in the studied brain region, and a group of age‐matched healthy controls. We used immunohistochemical analyses with artificial intelligence quantifications, expansion microscopy, synaptosome extractions, and Western blotting, to assess associations between antemortem MMSE scores and synapse densities, glial cell phenotypes, and pathological tau. Results We found a significant loss of presynapses (Synapsin 1+), excitatory postsynapses (PSD95+), and colocalized synapses (Synapsin1‐PSD95+) in the brains of demented compared to non‐demented and controls. Moreover, we observed an association between excitatory synapse loss and memory dysfunction (MMSE score) as well as rate of disease progression (MMSE loss/time). MMSE scores were further associated with increase in tau oligomers (TOC1+) and phospho‐tau (AT270+) in synaptosomes, but not with 4G8+ β‐amyloid burden. Additionally, disease severity and rate of progression were significantly correlated with inflammatory glial changes. Conclusions Our data suggest that excitatory synapse loss could serve as an early and robust neuropathologic correlate of disease severity and rate of progression from MCI stages of the disease, and be a closer and better determinant of cognitive decline than β‐amyloid and tau deposits. Moreover, early increases in soluble tau in synapses together with local inflammatory glial cell responses could drive development of incipient changes in memory function and serve as potential early biomarkers. Our results point to the importance of early detection and interventions aimed at synapse preservation from prodromal stages of AD, and suggest soluble tau and inflammatory glial cell changes as key targets in the early AD phases.