How the brain works
A family often finds it easier to accept the Alzheimer's patient's cognitive problems than his or her behavior problems, which may make the patient seem deliberately uncooperative, spiteful, or just plain mean. But both kinds of problems are consequences of the disease. A close look at the brain reveals how memory, intellectual abilities, emotions, and behavior are connected and how they become disconnected in Alzheimer's disease.
A macro view of the brain
Neuroscientist Paul MacLean coined the term "triune brain" to describe in evolutionary terms what he viewed as the three separate but interconnected levels of the human brain: the brainstem (and cerebellum), the limbic system, and the cerebral cortex (see Figure 1). An extensive two-way network of nerves connects these three levels of the brain. Ongoing communication between the cerebral cortex and the limbic system inextricably links thinking and emotions (see Figure 2). Each influences the other, and both direct all voluntary action. This interplay of memory and emotion, thought and action is the foundation of each individual's unique personality.
Figure 1: The three levels of the brain
The most primitive level of the brain is made up of the brainstem and cerebellum (1). The brainstem regulates the kinds of body functions you rarely stop to think about, such as your heartbeat, breathing rate, and blood pressure. The cerebellum coordinates posture, muscle tone, and skilled movements. The next level, the limbic system (2), provides the link between animal drives and rational behavior. The third level, the cerebral cortex (3), is the wrinkled "gray matter" that covers the brain. Less than a quarter-inch thick, the cerebral cortex is responsible for higher-level thought, memory, and language.
The brainstem and cerebellum
Operating at the first level, these two primitive structures control basic survival. The brainstem oversees vital functions such as heartbeat and body temperature, and the cerebellum orchestrates movement.
The limbic system
Nestled deep inside the brain is the limbic system, the second level of MacLean's "triune brain." This wishbone-shaped complex of nerve centers is found in all mammals. The limbic system links emotions and behavior, as numerous scientific experiments and observations of people with brain damage have proved. Stimulating one area of the limbic system produces feelings of anger and aggression, while stimulating another area prompts feelings of pleasure and relaxation. The limbic system is the interface between our animal drives and the constraints of civilization, between irrational impulses and practical decisions, between raw emotions and rational behavior.
The limbic system has another major function: It is central to memory and learning. Although memories are not stored in a single location, discrete structures within the limbic system orchestrate memory formation. Furthermore, these structures process different kinds of memory. The hippocampus, for example, is active in converting information into long-term memory and in memory recall. Repeated use of specialized nerve networks in the hippocampus enhances memory storage, so this structure is involved in learning from both commonplace experiences and deliberate study.
Damage to the hippocampus or its nerve connections can cause amnesia (inability to learn and then recall new information). People with amnesia are unable to form new long-term memories, and they forget information soon after they hear or see it. For example, researchers have found that patients with amnesia can continue doing things like playing checkers as well as they used to (because it was a skill that was acquired over years through practice), but they can't remember whom they're playing against.
But not all experiences in a person's life are indelibly etched in memory, nor is it necessary to retain every bit of information one encounters. This is where emotions enter the memory process. Some neuroscientists believe the hippocampus helps select which memories are stored, perhaps by attaching an "emotion marker" to some events or other information so they are more likely to be recalled.
The amygdala, which sits next to the hippocampus, is concerned with a different magnitude of emotional memory: It comes into play in situations that arouse feelings such as fear, anger, pity, or outrage. Researchers have discovered that memories that have an emotional component are more likely to be retained. But damage to the amygdala can abolish an emotion-charged memory. For example, an animal might no longer fear its predators.
The cerebral cortex
The third level of the brain is the cerebral cortex, commonly called the "gray matter." The cerebral hemispheres contain two specialized regions, one dedicated to voluntary movement and one to processing sensory information. But most of the gray matter is the association cortex, which becomes progressively larger as animals move up the evolutionary ladder. The association cortex is the region of conscious thought: It is where you store memory and language skills, process information, and carry out creative thinking.
Figure 2: Inside the brain
In Alzheimer's disease, brain cells die and neuronal connections wither in all parts of the brain, but especially in the hippocampus and the amygdala — important parts of the limbic system that coordinate memory storage and recall — and the cerebral cortex, the seat of higher-level thinking, memory, and language.
A micro view of the brain
Up close, the brain is a web of interconnecting cells called neurons. How these cells communicate and what happens when these cells die form the basis of our understanding of brain disease.
How brain cells communicate
The neuron is the brain's basic unit for processing information. The human brain contains an incredible number of neurons — about 100 billion, give or take 10 billion. The neuron is a unique cell in activity and appearance. It generates both electrical and chemical signals, making it able to communicate quickly with distant neurons. Instead of the compact shape typical of other cells in the body, the neuron is like an oak tree with giant branches stretched out. Each neuron has a body containing a nucleus, one long fiber called an axon, and many shorter branching fibers called dendrites.
The neuron is both a receiver and a transmitter. When a neuron receives a signal, it generates an electrical impulse. This impulse travels through the neuron and down the axon to its end (the axon terminal). The signal is then passed on to other neurons. Viewed under a microscope, neurons look like a dense forest of trees whose branches are so closely intertwined that they appear to touch. But when the details are highlighted with a silver stain, it is clear that each cell is separated from its neighbors by tiny gaps called synapses. Because the electrical signal cannot bridge this space, some other mechanism is required for a neuron to communicate with its neighbors. This is where the neuron's chemical signal comes in.
Stored in the axon terminal are chemical messengers called neurotransmitters. The electrical impulse opens tiny pores in the axon terminal, allowing a supply of neurotransmitters to flood into the synapse (see Figure 3). The chemical then attaches to receptors on a neighboring neuron. What happens next depends on whether the neurotransmitter has an exciting or inhibiting effect on the neuron.
Figure 3: How nerve cells communicate
An excitatory neurotransmitter passes the message on by creating an electrical impulse in the cell that receives it, and the process of electrical-to-chemical signaling is repeated. But if an impulse were to be transmitted to every neuron in the brain, the result would be chaos; much like a power surge can cause a short circuit, neurons firing all at once would cause a prolonged epileptic seizure. To safeguard against this happening, inhibitory neurotransmitters suppress communication to neighboring neurons.
Of the more than 20 chemical messengers discovered thus far, a few are fairly well understood. Several of them are involved in memory, including acetylcholine, serotonin, and dopamine. Many of these neurotransmitters have additional functions; for example, serotonin helps regulate sleep and sensory perception, while dopamine helps regulate movement.
As biological processes go, the speed of thought is rapid (although slow compared with a computer). Electrical impulses in some neurons reach speeds of nearly 200 mph, and transmission from cell to cell takes about a thousandth of a second. In addition, one nerve cell may have more than 1,000 synapses and, with a single impulse, can transmit simultaneously to all its neighbors.
When nerve cells die
The tremendous number of neurons and synapses in a normal brain provides a seemingly infinite capacity for processing information, as well as a margin of safety in case some are destroyed. But in Alzheimer's disease, the wholesale destruction of neurons eliminates this safety net, especially in the areas involved in memory and cognition — the association cortex, the limbic system, and their connecting nerve networks. Although research indicates that one day it may be possible to coax new neurons to grow (see "Nerve cell regeneration"), at this point such a feat is impossible.
Alzheimer's leaves two odd types of deposits in these areas. Inside the neurons of an Alzheimer's patient are neurofibrillary tangles, hairlike protein fibers twisted tightly together like yarn. Lying outside the neurons, near synapses, are neuritic plaques, made up of a protein core called beta-amyloid (also called a-beta or Aß) surrounded by debris from degenerating neurons (see Figure 4). These two features — neurofibrillary tangles and neuritic plaques — are the distinctive microscopic signatures of Alzheimer's disease.
Figure 4: Plaques and tangles
The brains of Alzheimer's patients contain neurofibrillary tangles inside neurons and clumps of fibers called neuritic plaques outside of neurons. A set of enzymes, called secretases, in the neurons cause plaques to form. The secretases snip pieces from a large amyloid precursor protein (APP), leaving behind fragments of amyloid proteins that snarl and clump with the debris of dying neurons (pieces of dendrites). In contrast to the neuritic plaques, neurofibrillary tangles form within neurons and are composed of aggregates of a different protein known as tau.
Beta-amyloid is a peptide composed of approximately 40 amino acids. Research has shed light on the chemical process responsible for the formation and deposit of this sticky, starchlike protein in the brains of Alzheimer's patients. This understanding has prompted pharmaceutical companies to start manufacturing drugs to block the formation of amyloid deposits (see "Amyloid production blockers").
These tangles and plaques, first described by Alois Alzheimer in 1907, have been the main focus of research for decades, and for good reason: The worse the mental deterioration, the more amyloid and tangles are found in brain tissue. The prevailing view among neurologists used to be that these deposits caused the mental changes in Alzheimer's disease.
However, tangles and plaques are not unique to this condition. Some are found in other dementing disorders, and a few are scattered about in the brains of healthy middle-aged and elderly people. Some neuroscientists have wondered if these occasional deposits might explain the mild forgetfulness associated with normal aging, but studies have cast doubt on this theory.
Studies now indicate that dementia in Alzheimer's patients is caused by the shrinkage and death of neurons and synaptic loss, not by tangles and plaques themselves. However, according to the leading hypothesis, amyloid deposits play an early role by setting in motion a cascade of biochemical events that causes the cells to shrink and die.
With advances in technology enabling them to count neurons, neuroscientists were able to make this discovery by examining brain tissue from 10 people with normal brain function who died after age 60. All the samples contained about the same number of neurons in an area of the association cortex richly supplied with nerves from the sensory region. For the first time, scientists had a standard for defining how many neurons were "normal" in the human brain. Furthermore, this finding indicated that neuron loss was not a product of normal aging.
Next, the researchers compared the normal samples with brain tissue from 10 people with Alzheimer's and discovered, on average, a 41% reduction in the number of neurons. And the longer dementia had been present, the fewer neurons were found. There was also a correlation with neurofibrillary tangles: People with the greatest neuron loss had more tangles, about 95% of which were inside the remaining neurons. However, loss of neurons was dramatically greater than the number of tangles.
The researchers offered "housekeeping" as a possible explanation for this discrepancy: Molecules that clear away dead cells in the body eventually removed the tangles. When they counted neuritic plaques, the researchers found no relationship with either neuron loss or disease duration, reinforcing the view that neuronal dysfunction and death cause dementia. Although tangles and plaques are still considered the diagnostic hallmarks of Alzheimer's disease, synaptic loss and neuron death correlate best with dementia.
Experts also believe that decreased levels of the neurotransmitter acetylcholine, a chemical that bridges synapses between neurons that affect memory, also contribute to the memory loss of Alzheimer's disease. In the cortex and hippocampus, where this neurotransmitter is needed for memory and learning, the acetylcholine-producing neurons (called cholinergic neurons) are normally plentiful. But of the several types of neurons that can degenerate in Alzheimer's disease, the cholinergic neurons are especially hard hit. As acetylcholine production falls in the cortex and hippocampus, dementia becomes progressively worse. By the time someone with Alzheimer's disease dies, the cortex may have lost 90% of its acetylcholine.
Other neurotransmitter abnormalities may also be present. Reduced levels of serotonin and noradrenaline have been found in some people with Alzheimer's disease. Imbalances among these and other neurotransmitters could explain why some patients experience sensory disturbances, depression, sleep problems, aggressive behavior, and mood swings.
Nerve cell regeneration
For decades, the accepted wisdom has been that neurons can't regenerate. Scientists used to believe that we are born with a certain number of neurons, and once they die, they are gone forever. But research has turned this theory on its head.
Scientists have discovered that adults do grow new neurons, and that some of this regeneration takes place in the hippocampus, a structure that is devastated by Alzheimer's disease. This hopeful finding raises the possibility of using the brain's regenerative system to replace cells that are lost in diseases of aging, such as Alzheimer's. For example, scientists are looking into ways to recreate brain cells in the cerebral cortex by manipulating precursor cells.
Dr. Jeffrey D. Macklis, associate professor of neurology at Harvard Medical School, has shown that under the right conditions, precursor cells, or stem cells, introduced into adult mice selectively migrate into regions of the brain that have degenerated. Furthermore, these cells can grow into neurons that are indistinguishable from their healthy, normal neighbors. Besides offering promise for treating degenerative brain diseases such as Alzheimer's and Parkinson's, this technique for regenerating nerve cells may ultimately be useful for any number of conditions that affect the central nervous system, such as spinal cord injuries.
This is a great program That was sent to me to add to this article from Titus Dalisay
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