Alzheimer’s & Dementia - (2018) 1-11

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1 56
2 Featured Article 57
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Genetic overlap between vascular pathologies and Alzheimer’s dementia 60
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and potential causal mechanisms 62
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9 64
a,b c,d c,d e
10Q8 Yen-Feng Lin , Albert Vernon Smith , Thor Aspelund , Rebecca A. Betensky , 65
11 b,f,g,h c,d i b,g,j, 66
Jordan W. Smoller , Vilmundur Gudnason , Lenore J. Launer , Deborah Blacker * 67
12 a
13 Department of Psychiatry, Taipei City Psychiatric Center, Taipei City Hospital, Taipei, Taiwan 68
b
14 Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, MA, USA 69
c
15 Icelandic Heart Association, Kopavogur, Iceland 70
d
16 Faculty of Medicine, University of Iceland, Reykjavik, Iceland 71
e
17 Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, MA, USA 72
f
18 Psychiatric and Neurodevelopmental Genetics Unit, Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA 73
g
19 Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA 74
h
20 Stanley Center for Psychiatric Research, Broad Institute of MIT and Harvard, Cambridge, MA, USA 75
i
21 Laboratory of Epidemiology and Population Sciences, National Institute of Ageing, National Institutes of Health, Bethesda, MD, USA 76
j
22 Gerontology Research Unit, Massachusetts General Hospital, Boston, MA, USA 77
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24 79
25 Abstract Introduction: We sought to examine the genetic overlap between vascular pathologies and Alz- 80
26 81
heimer’s disease (AD) dementia, and the potential mediating role of vascular pathologies between
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AD-related genetic variants and late-life cognition. 83
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Methods: For 2907 stroke-free older individuals, we examined the association of polygenic risk scores 84
29
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for AD dementia (ADPRSs) with vascular pathologies and with cognition. Mediation analyses ad- 85
31 dressed whether association between ADPRSs and cognition was mediated by a vascular pathology. 86
32 Results: ADPRSs were associated with lobar cerebral microbleeds, white matter lesion load, and 87
33 coronary artery calcification, mostly explained by single nucleotide polymorphisms in the 19q13 re- 88
34 gion. The effect of ADPRSs on cognition was partially but significantly mediated by cerebral micro- 89
35 bleeds, white matter lesions, and coronary artery calcification. 90
36 Discussion: Our findings provide evidence for genetic overlap, mostly due to apolipoprotein E 91
37Q1 92
(APOE), between vascular pathologies and AD dementia. The association between AD polygenic
38 93
risk and late-life cognition is mediated in part via effects on vascular pathologies. 94
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Ó 2018 Published by Elsevier Inc. on behalf of the Alzheimer’s Association. 95
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42 97
Keywords: Alzheimer’s dementia; Polygenic risk score; Cerebral microbleeds; White matter lesions; Coronary calcification;
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Cognitive impairment; Causal mediation
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48 1. Background derlying AD pathology, the accumulation of amyloid 103
49 plaques and neurofibrillary tangles, which may lead to neu- 104
50 The etiology of Alzheimer’s disease (AD) dementia is 105
rodegeneration and neuronal cell death. However, it is well-
51 complex and multifactorial. AD dementia refers to the clin- 106
established that a large fraction of those with a diagnosis of 107
52 ical diagnosis of dementia considered likely to be due to un-
53
AD dementia also have cerebrovascular pathology [1]. Sys- 108
54 tematically collected cohort-based autopsy data have shown 109
that vascular pathology often coexists with AD pathology,
The authors have declared that no conflict of interest exists. adds to the likelihood of cognitive impairment, and lowers
*Corresponding author. Tel.: 11-617-726-5571; Fax: 11-617-726- the threshold of AD pathology for the development of clin-
5760.
E-mail address: blacker@psych.mgh.harvard.edu
ically diagnosed AD dementia [2].

https://doi.org/10.1016/j.jalz.2018.08.002
1552-5260/Ó 2018 Published by Elsevier Inc. on behalf of the Alzheimer’s Association.

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110 A variety of cerebral small vessel diseases (SVDs) have AD dementia and each of the following vascular pathol- 177
111 been associated with AD dementia. Cerebral microbleeds ogies: lobar CMBs, WMLs, RVD, CIMT, and CAC. We 178
112 179
113
(CMBs) are more prevalent in individuals with dementia also generated two partitioned ADPRSs, estimating ge- 180
114 [3–5]. The presence of CMBs in deep and infratentorial netic risk for AD dementia contributed separately by 181
115 regions is generally ascribed to hypertensive vasculopathy, the 19q13 region that includes APOE and SNPs in link- 182
116 while a lobar distribution of CMBs is associated with age disequilibrium with APOE, and all other SNPs 183
117 cerebral amyloid angiopathy (CAA) [6], which has been outside of the APOE-linkage region. We tested each 184
118 185
119
considered a major contributor to the pathogenesis of AD de- ADPRS separately for association with cognition scores 186
120 mentia [7]. White matter lesions (WMLs), an imaging and with each vascular pathology. For vascular markers 187
121 marker of cerebral SVDs, may also play a role in the devel- observed to be genetically correlated with AD dementia, 188
122 opment of AD dementia [8,9]. A meta-analysis found that we performed mediation analyses to explore the causal 189
123 WMLs predicted an increased risk of AD and other dementia relationship among ADPRSs, vascular pathologies, and 190
124 191
125
[10]. Retinal venular diameter (RVD), an indicator to visu- cognitive function. 192
126 alize microcirculation in vivo, has been related to WMLs, 193
127 brain atrophy, and increased risk of dementia [11–13]. 2. Methods 194
128 Research efforts have also been devoted to the association 195
129 between large vessel disease and AD dementia. Possible 2.1. Study sample 196
130 197
131
mechanisms linking large-vessel atherosclerosis to AD de- 198
The analyses were performed in data from the Age, Gene/
132 mentia include shared etiology and brain hypoperfusion 199
Environment Susceptibility–Reykjavik Study (AGES-Rey-
133 [14]. Several longitudinal studies suggest that carotid 200
134
kjavik), a population-based cohort in Iceland [31] (see 201
intima-media thickness (CIMT), a marker of atherosclerosis,
135 Supplementary Methods). For our phenotypic analyses, 202
is associated with brain atrophy [15] and a later incidence of
136 from the full AGES-Reykjavik sample of 5764 participants, 203
137
AD dementia [16,17]. Atherosclerotic coronary artery 204
we excluded those with a history of stroke or vascular de-
138 calcification (CAC) is another marker of large vessel 205
mentia, leaving 5161. Of these participants, the 2907 with
139 disease. Although there have been few reports on the 206
140
clean genotype data available constituted the sample for 207
relation between CAC and AD, current evidence suggests
141 our genetic analyses (see Supplemental Figure S1). Geno- 208
that larger volume of CAC is associated with brain
142 typing was performed using the Illumina HumanCNV370- 209
143
atrophy, worse cognitive function, and all-cause dementia 210
Duo (Illumina Inc., San Diego, CA, USA). Rigorous quality
144 [18–20]. 211
control procedures were performed on the genotyped
145 Genetic studies may provide clues to the biological link 212
146
markers and individuals. Nongenotyped markers were 213
of AD dementia with cerebrovascular and cardiovascular
147 imputed using the 1000 Genomes-V3-phase I reference 214
disease (collectively “CVD”). Apolipoprotein E (APOE),
148 panel (see Supplementary Methods). 215
149
the major susceptibility gene for AD [21], has been reported 216
150 to be a risk factor for hyperlipidemia, lobar CMBs, WMLs, 217
151 ischemic stroke, and coronary heart disease [22–25]. In 2.2. Vascular pathology markers 218
152 addition to APOE, genome-wide association studies 219
Markers of vascular pathologies were measured with
153 (GWASs) of AD dementia have identified single nucleotide 220
154 standard protocols and assessed by well-trained raters 221
155
polymorphisms (SNPs) with known or hypothesized rela- (see Supplementary Methods). We systematically exam- 222
156 tionships to lipid metabolism, such as CLU, ABCA7, and ined cerebrovascular and cardiovascular markers in our an- 223
157 SORL1 [26]. Recent studies using large-scale GWAS data alyses, including lobar CMBs (binary; multiple [
2] vs. 224
158 suggest that AD dementia may be genetically correlated 225
nonmultiple [0 or 1]), WML load (binary; the highest quar-
159 with levels of biomarkers for CVD risk (plasma lipids and 226
160 tile vs. the lower three), RVD (continuous), CIMT (contin- 227
161
C-reactive protein) [27] and small vessel stroke [28]. A uous; log-transformed), and CAC (continuous; log- 228
162 gene-based pathway approach to GWAS data has also iden- transformed). 229
163 tified shared genetic pathways between CVD and AD de- 230
164 mentia [29]. 231
165 2.3. Measures of cognitive function 232
A recent study found that the effect of APOE-ε4 on
166 233
167
late-life cognition was partially mediated by cerebrovas- Participants received a comprehensive cognitive assess- 234
168 cular pathologies [30]. In the present study, we expand to ment battery including tests of memory, executive function, 235
169 additional vascular pathologies beyond the brain and and processing speed. Based on the scores of domain- 236
170 full-genome data to more fully understand the relation- specific cognitive tests, we calculated the Z-score of the 237
171 ship of AD genes and vascular pathology in the develop- composite memory score and the Z-score of the composite 238
172 239
173
ment of cognitive impairment. We generated genome- global cognition score, as the main cognitive outcomes for 240
174 wide polygenic risk scores for AD dementia (GW- our analyses (see Supplementary Methods and 241
175 ADPRSs) to examine the polygenic overlap between Supplemental Figure S2). 242
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244 2.4. Other covariates uous phenotypes) or logistic (for binary phenotypes) 311
245 regression models to test the association of each phenotype 312
246Q2 Other covariates used in the analyses included age, sex, 313
247
with each of GW-ADPRS, 19q13-ADPRS, and non-19q13- 314
education, smoking status, midlife physical activity, diet ADPRS, adjusting for age and sex. The Wald test P-value
248 315
quality, prevalent diabetes, hypertension, high LDL level, for each association test was reported, and squared semi-
249 316
250 and obesity (see Supplementary Methods). partial correlations (R2) were calculated to estimate the 317
251 proportion of variance explained by the PRSs. We used 318
252 319
253
2.5. Polygenic risk scores for AD dementia Bonferroni correction to adjust for multiple testing (see 320
254 Supplementary Methods). 321
2.5.1. Genome-wide ADPRSs
255 322
256 We used the summary statistics from the Alzheimer’s 2.6.3. Causal mediation analyses 323
257 Disease Genetics Consortium GWAS (8309 AD cases and We performed mediation regression analyses [33], based 324
258 7366 controls of European ancestry) [32] as the discovery 325
259
on the counterfactual framework for causal inference [34], to 326
data set to calculate GW-ADPRSs in our study sample. We examine how much of the effect of an ADPRS on cognition
260 327
applied a linkage disequilibrium clumping procedure to scores was mediated by a vascular pathology observed to be
261 328
262 the discovery data sets, retaining the SNP with smallest P- genetically correlated with AD dementia. 329
263 value in each 250 kb window and removed all those in link- For each ADPRS (GW-ADPRS, 19q13-ADPRS, or 330
264 age disequilibrium (r2 . 0.2) with this SNP. We used three non-19q13-ADPRS) as the predictor, we estimated the
331
265 association P-value thresholds (PTs), .0001, .001, and .01, 332
266 direct and indirect (mediated) effects of each vascular pa- 333
to select index SNPs from the clumped independent SNPs thology as the mediator, and Z-score of the composite
267 334
268 for generating the PRSs. For each individual, and each PT, memory or global cognition score as the outcome. To 335
269 we calculated GW-PRSs by summing the risk allele counts gain more statistical power, the ADPRS predictors used 336
270 of the index SNPs, weighted by the log of their association 337
271
in the mediation analyses were those with the PT that 338
odds ratios estimated from the Alzheimer’s Disease Genetics showed the highest association with each cognitive
272 339
Consortium GWAS results. outcome. We adjusted for potential mediator-outcome
273 340
274 confounders, including age, sex, smoking status, midlife 341
275 2.5.2. 19q13-ADPRS and non-19q13-ADPRS physical activity, diet quality, and other genetic risk scores 342
276 Because APOE is the strongest risk gene for AD demen- 343
277
if necessary. A counterfactual outcome variable denotes Q3 344
tia, we further partitioned the GW-ADPRSs into an APOE the outcome that would have been observed had a predic-
278 345
region score and a non-APOE region score to separately tor been set to a particular value. To compare high and
279 346
280 assess the polygenic effects of SNPs in the APOE-linkage re- low values of each ADPRS in our estimates of the direct 347
281 gion 19q13 (ch19:4500000-4580000) and all other SNPs. and the indirect effects, we chose to compare the 75th 348
282 We followed the same steps as for the calculation of the 349
283
percentile and the 25th percentile of each. 350
GW-ADPRSs to generate a 19q13-ADPRS (the summation Finally, we conducted sensitivity analyses of unmeasured
284 351
of log-odds ratio–weighted risk allele counts of the index confounding and the choice of 75th versus 25th percentile
285 352
286 SNPs in the 19q13 region) and a non-19q13-ADPRS (the comparison (see Supplementary Methods). 353
287 summation of log-odds ratio–weighted risk allele counts of All the mediation analyses were performed by using the 354
288 the index SNPs across whole genome except 19q13) for 355
289
PARAMED module in STATA [35]. We used bootstrap pro- 356
each individual. cedures with 200 replications to compute a 95% bias-
290 357
291 corrected bootstrap confidence interval (95% BCCI) for 358
292 2.6. Data analysis the direct and indirect effects. 359
293 360
294 2.6.1. Phenotypic associations of vascular markers with 361
295 cognition 362
296 3. Results 363
We used univariate and multivariate linear regressions to
297 364
298 assess the associations of each vascular marker with the 365
3.1. Sample characteristics
299 cognitive outcomes. Multivariate models adjusted for age, 366
300 sex, education, diabetes, hypertension, high LDL level, Table 1 presents descriptive statistics for the AGES sam- 367
301 obesity, physical activity, diet quality, and smoking status. ple used here. The mean age of all subjects without stroke or 368
302 369
vascular dementia (n 5 5161) was 76.7 (5.8) years. Vascular
303 370
304 2.6.2. Association of ADPRSs with vascular and cognitive pathologies were relatively rare: for example, only 2% had 371
305 phenotypes multiple lobar CMBs. Subjects with genotype data available 372
306 We examined if any of the PTs generates an ADPRS (n 5 2907) were similar to the full sample but had somewhat 373
307 significantly associated with each of the cognitive out- a lower coronary calcification score (with vs. without geno- 374
308 375
comes and vascular pathologies. We used linear (for contin- types; Mann-Whitney U test, P 5 .01).
309 376
310 377

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378 Table 1 445

379 Descriptive statistics of demographic and clinical characteristics 446
380 447
Characteristics All subjects (N 5 5161) Subjects with genotype data (N 5 2907)
381 448
382 Demographic 449
383 Age at AGES I (years), mean (SD) 76.73 (5.83) 76.20 (5.43) 450
384 Sex 451
385 Female, N (%) 3022 (58.6) 1706 (58.7) 452
386 Education 453
387 Secondary, N (%) 2406 (49.9) 1441 (49.7) 454
388 College, N (%) 755 (15.7) 451 (15.6) 455
389 University, N (%) 547 (11.4) 334 (11.5) 456
390 Vascular pathologies, baseline 457
391 Lobar cerebral microbleeds 458
392 Count
2, N (%) 110 (2.1) 69 (2.7) 459
393 White matter lesion load, median (Q1, Q3) 1.91 (0.51, 5.64) 1.92 (0.50, 5.59) 460
394 Central retinal venular equivalent, mean (SD) 202.19 (19.56) 202.14 (19.50) 461
395 Carotid intima-media thickness, median (Q1,Q3) 0.97 (0.88, 1.06) 0.97 (0.88, 1.06) 462
396 Coronary calcification score, median (Q1, Q3) 271.23 (43.61, 898.78) 253.52 (38.94, 841.53) 463
397 Other covariates, baseline 464
398 Midlife physical activity 465
399 Intermediate, N (%) 2166 (46.6) 1327 (47.5) 466
400 Poor, N (%) 909 (19.5) 524 (18.8) 467
401 Diet quality 468
402 Intermediate, N (%) 4011 (84.6) 2418 (84.8) 469
403 Poor, N (%) 354 (7.5) 205 (7.2) 470
404 Smoking 471
405 Ever, N (%) 2111 (43.9) 1303 (44.8) 472
406 Current, N (%) 593 (12.3) 372 (12.8) 473
407 Diabetes, N (%) 640 (12.4) 324 (11.2) 474
408 Hypertension 475
409 Prehypertension, N (%) 758 (14.8) 445 (15.3) 476
410 Hypertension, N (%) 4112 (80.3) 2318 (79.8) 477
411 LDL level
130 mg/dL, N (%) 2830 (54.9) 1643 (56.6) 478
412 BMI
30, N (%) 1139 (22.3) 642 (22.1) 479
413 480
Abbreviations: BMI, body mass index; GWAS, genome-wide association study.
414 481
NOTE. Subjects with GWAS genotype data available (n 5 2907) had lower coronary calcification score than those without genotype data (n 5 2254) (Mann-
415 482
Whitney U test, P 5 .01). No significant difference was observed in the distribution of any other characteristic listed in the Table between subjects with and
416 483
without genotype data available.
417 484
418 3.2. Phenotypic associations confounders, CMBs, CAC, and WMLs were significantly 485
419 486
420
associated with the memory score, whereas the former two 487
Table 2 presents phenotypic associations between each were significantly associated with the global cognition
421 488
vascular pathology and cognitive outcomes. All unadjusted
422 score. 489
423 associations were significant. After adjusting for potential 490
424 491
425 Table 2 492
426 Phenotypic associations between vascular pathologies and late-life cognitive function 493
427 Memory Global cognition 494
428 495
429 Unadjusted Adjusted Unadjusted Adjusted 496
430 Vascular pathologies b (S.E.) P b (S.E.) P b (S.E.) P b (S.E.) P 497
431 498
432 Lobar CMB 20.368 (0.097) 1.5E-04* 20.187 (0.086) .03* 20.443 (0.100) 8.9E-06* 20.268 (0.083) .001* 499
433 WML 20.193 (0.036) 1.1E-07* 20.070 (0.033) .03* 20.244 (0.037) 6.0E-11* 20.060 (0.032) .06 500
434 RVD 0.002 (0.001) 0.01* 20.001 (0.001) .53 0.003 (0.001) .001* 0.0004 (0.0007) .56 501
435 CIMT 21.110 (0.105) 6.3E-26* 20.107 (0.102) .29 21.004 (0.109) 4.5E-20* 0.073 (0.099) .46 502
436 CAC 20.086 (0.006) 1.5E-46* 20.015 (0.006) .01* 20.087 (0.006) 2.4E-45* 20.023 (0.006) 7.8E-05* 503
437 504
Abbreviations: Lobar CMB, multiple lobar cerebral microbleeds (count
2 versus 0 or 1); WML, white matter lesion load (highest quartile versus other three
438 505
quartiles of the total volume of white matter lesions); RVD, retinal venular diameter (represented by central retinal venular equivalent, continuous); CIMT,
439 506
carotid intima-media thickness (log-transformed, continuous); CAC, coronary artery calcification score (log-transformed, continuous).
440 507
NOTE. All multivariate models adjusted for age, sex, education, diabetes, hypertension, high LDL level, obesity, physical activity, diet quality, and smoking
441 508
status. If all potential confounders remain constant, those with multiple lobar CMBs had, on average, 0.19 SD lower memory score and 0.26 SD lower global
442 509
cognition score than those with 0 or 1 lobar CMBs. Individuals in the highest quartile of WML load had 0.07 SD lower memory score than others. For each one-
443 510
unit increase in log-transformed CAC, the mean memory and global cognition scores declined by 0.015 SD and 0.023 SD, respectively.
444 511
*Indicates significance at P , .05.

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512 WMLs and between higher GW-ADPRSPT 5 .0001 and 579

513 higher CAC. 580
514 581
515 582
516 3.4. Associations of 19q13-ADPRS and non-19q13- 583
517 ADPRS with cognitive or vascular phenotypes 584
518 585
519 Our data showed that higher 19q13-ADPRS at all three 586
520 PTs were significantly associated with having lobar CMBs. 587
521 We also found nominal associations of higher 19q13- 588
522 589
523
ADPRS with greater WMLs, higher CAC, and poorer per- 590
524 formance on both cognitive outcomes (Table 3). For a non- 591
525 19q13-ADPRS, the only association was that between 592
526 higher non-19q13-ADPRSPT 5 .01 and lower memory score 593
527 (Table 3). 594
528 595
529 596
530 3.5. Mediation analyses 597
531 598
532 The PRS that most associated with each cognitive 599
533 outcome was selected as the predictor (GW-ADPRSPT 5 600
534 .01, 19q13-ADPRSPT 5 .001, and non-19q13-ADPRSPT 5 .01 601
535 for memory; GW-ADPRSPT 5 .0001, 19q13-ADPRSPT 5 602
536 603
537 .001, and non-19q13-ADPRSPT 5 .01 for global cognition). 604
538 Vascular pathologies with a P-value lower than 0.05 for 605
539 PRS associations with AD dementia were tested as potential 606
web 4C=FPO

540 mediators (CMBs, WMLs, and CAC). 607

541 Results are shown in Table 4. The proportion mediated 608
542 609
543
was obtained by dividing the estimated indirect effect by 610
544 the estimated total effect, as an index of the degree of medi- 611
Fig. 1. Pairwise polygenic association analyses between GW-ADPRS and
545 (A) cognition scores, (B) vascular pathologies. We derived genome-wide
ation. The total effect of GW-ADPRSs on the memory score 612
546 PRS for AD dementia using Alzheimer’s Disease Genetics Consortium was significantly mediated by multiple lobar CMBs and 613
547 GWAS as the discovery sample with three different P-value thresholds WML load. CMBs, WMLs, and CAC were all identified as 614
548 (PT used to select training set SNPs: .0001, .001, and .01) and apply them 615
549
significant mediators of the effects of GW-ADPRSs on the 616
to (A) Z-score of the composite memory or global cognition score and global cognition score. The total effect of the 19q13-
550 (B) each of the markers of vascular pathologies. Age and sex were included 617
551 as covariates in the association analyses. Each pair is shown on the x-axis
ADPRS on the memory score was significantly mediated 618
552 and the proportion of variance explained for each phenotype (estimated by CMBs and WMLs, and its effect on global cognition 619
553 via partial correlation R2) on the y-axis. Unadjusted P-values are shown was mediated by CMBs, WMLs, and CAC. The total effect 620
554 on the top of the bars if , .05. An asterisk (*) indicates Bonferroni- 621
555
of the non-19q13-ADPRS on both memory and global 622
corrected P-value , .05. Abbreviations: SNP, single nucleotide polymor- cognition was mediated by CMBs.
556 phism; AD, Alzheimer’s disease; ADPRS, polygenic risk score for AD de- 623
557 mentia; GWAS, genome-wide association study.
When an interaction between the PRS and the vascular 624
558 mediator was included in each mediation model, there was 625
559 very little change in the estimated direct and indirect effects, 626
560 627
561 3.3. Associations of GW-ADPRSs with cognitive or so we decided not to include the interaction in the mediation 628
562 vascular phenotypes models, as suggested by Vanderweele [33]. 629
563 630
564 Results are shown in Fig. 1 and Table 3. The lower 631
3.6. Sensitivity analyses
565 memory score was significantly associated with higher 632
566 GW-ADPRSs with a P-value threshold of .0001 (GW- Sensitivity analyses of unmeasured confounding suggest 633
567 ADPRSPT 5 .0001; P 5 .006, R2 5 0.22%) and higher GW- that under the seemingly more likely scenarios of unmea- 634
568 635
569
ADPRS with a P-value threshold of .01 (GW-ADPRSPT 5 sured confounders associated with better cognition and 636
.01; P 5 .001, R 5 0.29%), after the Bonferroni correction.
2
570 less severe vascular pathology, or unmeasured confounders 637
571 We also found nominal associations of lower global cogni- associated with poorer cognition and more severe vascular 638
572 tion scores with higher GW-ADPRSPT 5 .0001 and higher pathology, our estimated proportion mediated would under- 639
573 GW-ADPRSPT 5 .01. In terms of the association between estimate the true mediation effects of vascular pathologies 640
574 641
575
the GW-ADPRSs and vascular pathologies, we found that (see Fig. 2, Supplementary Results, Table S1, and 642
576 higher GW-ADPRSs at all three PTs were nominally associ- Figure S3). 643
577 ated with multiple lobar CMBs. There were also nominal as- Sensitivity analyses for selection of predictor levels for 644
578 sociations between higher GW-ADPRSPT 5 .01 and greater comparison found that mediation analyses comparing the 645

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646 Table 3 713

647 Associations between polygenic risk scores for AD dementia and each target phenotype 714
648 715
PRS for AD dementia Cognitive outcomes Vascular marker mediators
649 716
650 Memory Global cognition Lobar CMB WML RVD CIMT CAC 717
651 Genomic region P-threshold nSNP (n 5 2752) (n 5 2582) (n 5 2562) (n 5 2559) (n 5 2682) (n 5 2777) (n 5 2869) 718
652 719
GW-ADPRS ,0.0001 190 R2 5 0.0022 R2 5 0.0015 R2 5 0.0030 R2 5 0.0012 R2 5 0.0004 R2 , 0.0001 R2 5 0.0014
653 720
P 5 .006y P 5 .02* P 5 .006* P 5 .07 P 5 .29 P 5 .71 P 5 .03*
654 721
,0.001 1342 R2 5 0.0012 R2 5 0.0006 R2 5 0.0029 R2 5 0.0011 R2 , 0.0001 R2 5 0.0001 R2 5 0.0004
655 722
P 5 .04* P 5 .14 P 5 .007* P 5 .09 P 5 .90 P 5 .61 P 5 .24
656 723
,0.01 8918 R2 5 0.0029 R2 5 0.0012 R2 5 0.0018 R2 5 0.0018 R2 5 0.0002 R2 , 0.0001 R2 5 0.0005
657 724
P 5 .001y P 5 .04* P 5 .03* P 5 .03* P 5 .49 P 5 .99 P 5 .19
658 725
19q13-ADPRS ,0.0001 40 R2 5 0.0015 R2 5 0.0013 R2 5 0.0038 R2 5 0.0014 R2 5 0.0003 R2 5 0.0002 R2 5 0.0012
659 726
P 5 .02* P 5 .04* P 5 .002y P 5 .05 P 5 .40 P 5 .46 P 5 .04*
660 727
,0.001 54 R2 5 0.0015 R2 5 0.0013 R2 5 0.0035 R2 5 0.0018 R2 5 0.0002 R2 5 0.0002 R2 5 0.0015
661 728
P 5 .02* P 5 .04* P 5 .003y P 5 .03* P 5 .48 P 5 .48 P 5 .02*
662 729
,0.01 76 R2 5 0.0012 R2 5 0.0011 R2 5 0.0040 R2 5 0.0019 R2 5 0.0002 R2 5 0.0003 R2 5 0.0015
663 730
P 5 .04* P 5 .06 P 5 .002y P 5 .02* P 5 .46 P 5 .30 P 5 .02*
664 731
Non-19q13-ADPRS ,0.0001 150 R2 5 0.0008 R2 5 0.0002 R2 , 0.0001 R2 , 0.0001 R2 5 0.0002 R2 5 0.0001 R2 5 0.0001
665 732
P 5 .10 P 5 .39 P 5 .94 P 5 .82 P 5 .50 P 5 .50 P 5 .49
666 733
,0.001 1288 R2 5 0.0002 R2 , 0.0001 R2 5 0.0004 R2 5 0.0001 R2 5 0.0001 R2 , 0.0001 R2 , 0.0001
667 734
P 5 .45 P 5 .81 P 5 .30 P 5 .68 P 5 .67 P 5 .94 P 5 .71
668 735
,0.01 8842 R2 5 0.0020 R2 5 0.0006 R2 5 0.0005 R2 5 0.0008 R2 5 0.0004 R2 , 0.0001 R2 5 0.0001
669 736
P 5 .008y P 5 .15 P 5 .27 P 5 .14 P 5 .31 P 5 .70 P 5 .59
670 737
671 Abbreviations: AD, Alzheimer’s disease; ADPRS, polygenic risk score for AD dementia; SNP, single nucleotide polymorphism. 738
672 NOTE. P-threshold (PT): the P-value threshold used in the training data set to select SNPs for calculating the PRS for AD dementia; nSNP: different number 739
673 of independent SNPs included for calculating the PRS for AD dementia, which is determined by the selection of PT; Lobar CMB: lobar cerebral microbleeds 740
674 (count .52 vs. 0 or 1); WML: total brain white matter lesion load (highest quartile vs. other three quartiles of the total volume of white matter lesions); RVD: 741
675 the average retinal venular diameter, represented by central retinal venular equivalent (continuous); CIMT: mean of carotid intima-media thickness (log-trans- 742
676 formed, continuous); CAC: coronary artery calcification score (log-transformed, continuous); R2: squared semi-partial correlation, the proportion of variance in 743
677 the target phenotype explained by the PRS for AD dementia; P: the P-value of the test for association between the PRS and the target phenotype, before multiple 744
678 testing correction. 745
679 Associations were tested using linear (for continuous phenotype) or logistic (for binary phenotype) regression models with age and sex as covariates. The 746
680 missing data status of each vascular marker was associated neither with memory/global cognition scores nor with any of the PRS (all P . .20). 747
681 *Indicates significance at P-value ,.05. 748
682 y 749
Indicates significance after Bonferroni correction. We considered a PRS-wise significant threshold for the correction of multiple comparisons (P ,.008, after
683 Bonferroni correction for the six association tests between two cognitive outcomes and three ADPRSs for each genomic region; and P , .003, Bonferroni 750
684 correction for the 15 association tests between five vascular pathologies and three ADPRS). 751
685 752
686 753
687 754
688 effects of the 90th percentile and the 10th percentile of each In a relatively large sample of older adults, our pheno- 755
689 ADPRS yielded very similar proportion mediated as those typic analyses replicated previously reported phenotypic as- 756
690 757
691
shown in Table 4 (see Supplementary Table S2). sociations of cerebral SVDs [36,37] and atherosclerosis [18] 758
692 with cognitive function. We further examined if shared ge- 759
693
4. Discussion netic factors contribute to these associations and found ge- 760
694 netic overlap between AD dementia, vascular pathologies, 761
695 In a community-based sample of 5161 stroke-free older and late-life cognition (Table 3 and Fig. 1). Our data showed 762
696 763
697
individuals, we found that multiple lobar CMBs, higher that lobar CMBs, WML load, and CAC score were associ- 764
698 WML load, and greater CAC—but not RVD nor CIMT— ated with GW-ADPRSs and were even more strongly associ- 765
699 were associated with poorer late-life memory and global ated with 19q13-ADPRSs. Our findings of the strongest 766
700 cognition. In the 2907 genotyped individuals, we found genetic overlap between AD dementia and CMBs are consis- 767
701 that a higher genetic risk score for AD dementia, driven pri- tent with recently reported genetic correlation between AD 768
702 769
703
marily by APOE, was associated with these three vascular and cerebral SVDs but not large vessel disease [28]. Lobar 770
704 pathologies and two cognition outcomes. In mediation ana- CMBs may be caused by CAA [38,39], which is highly 771
705 lyses, we found that the effects of APOE and SNPs near prevalent in postmortem analyses of brains of persons with 772
706 APOE on memory may be partially mediated by CMBs clinical diagnosis of AD dementia [40]. In addition, the 773
707 and WMLs, and their effects on global cognition may be APOE-e4 allele has been associated with the presence of 774
708 775
709
partially mediated by CMBs, WMLs, and CAC. With the CAA [41,42]. These previous findings support the possible 776
710 possible exception of CMBs, there was little evidence of genetic overlap between lobar CMBs and AD dementia 777
711 an effect of non-APOE AD dementia–associated alleles on observed in our data. Because WMLs [43] and CAC [44] 778
712 either memory or global cognition. may share some common risk factors with CMBs, and 779

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780 both have been related to dementia (although the evidence 847

matter lesion load; highest quartile vs. other three quartiles of the total volume of white matter lesions), or CAC (coronary artery calcification score; log-transformed, continuous); Outcome: z-score of the memory

NOTE. Models for the effects of GW-ADPRSs adjusted for age, sex, smoking status, midlife physical activity, and diet quality. Models for the effects of 19q13-ADPRS adjusted for age, sex, smoking status,
2.004 (2.009, 2.002) 10.8%*
2.002 (2.006, 2.0003) 4.0%*
2.002 (2.006, 2.0001) 4.4%*
2.004 (2.013, 2.001) 11.3%*
2.002 (2.007, 2.0002) 4.8%*
2.002 (2.006, 2.0001) 5.0%*
2.002 (2.006, 2.0001) 7.5%*

NOTE. Predictor: GW-ADPRS, 19q13-ADPRS, and non-19q13-ADPRS (the 75th percentile vs. the 25th percentile); Mediator: CMB (lobar cerebral microbleeds; .52 vs. 0 or 1), WML (total brain white
3.7%
2.2%

midlife physical activity, diet quality, and non-19q13-ADPRS. Models for the effects of non-19q13-ADPRS adjusted for age, sex, smoking status, midlife physical activity, diet quality, and 19q13-ADPRS.
781 is not as strong as that for CMBs), a genetic overlap of AD 848
782 PM 849
783
dementia with WMLs and CAC makes sense. On the other 850
hand, we found no association between ADPRS and RVD,

2.001 (2.005, .0003)

784 851

2.001 (2.004, .001)

785 which has been reported as an indicator of cerebral small- 852
786 vessel pathology [12] and a predictor of dementia [11]. 853
Indirect effect
(95% BCCI)

787 One possible explanation is that the central retinal venular 854
788 855
789
equivalent is observer dependent and may not accurately 856
790 reflect the degree of retinal venular dilatation, but there is 857
791 no indication of even an attenuated signal. 858

Abbreviations: AD, Alzheimer’s disease; ADPRS, polygenic risk score for AD dementia; SNP, single nucleotide polymorphism; BCCI, bias-corrected confidence interval.
2.045 (2.096, 2.0004)

composite score (left panel) or z-score of the global cognition composite score (right panel); Values for total, direct, and indirect effects indicate changes in each outcome.
2.046 (2.092, 2.001)

792 Our results suggest that the APOE gene explains most 859
2.034 (2.076, .013)
2.039 (2.085, .013)

2.032 (2.079, .015)

2.038 (2.088, .012)

2.026 (2.074, .019)

2.028 (2.073, .018)
2.031 (2.077, .015)

793 of the SNP-based genetic overlap of AD dementia with 860

794 861
795
the vascular pathologies (see Supplementary Methods 862
(95% BCCI)
Direct effect

796 and Results on “Conditional Regression Analyses” and 863

797 Supplementary Table S6). APOE has been related to cere- 864
798 brovascular dysfunction by affecting cerebral blood flow, 865
799 blood-brain barrier integrity, and neuronal-vascular 866
2.048 (2.093, 2.003)

2.048 (2.100, 2.003)

800 867
2.038 (2.081, .008)
2.041 (2.087, .011)

2.036 (2.090, .009)

2.040 (2.091, .008)

2.028 (2.075, .016)

2.029 (2.075, .017)
2.031 (2.078, .015)

coupling [45]. As mentioned previously, the APOE-e4

*Indicates that the estimated indirect effect is significantly different from zero at the 5% level and that the PM is significantly greater than 0.
801 868
Global cognition

802 allele is a risk factor for CAA [41,42]. In terms of 869

803 peripheral vascular disease, APOE has been shown to 870
(95% BCCI)
Total effect

804 be an important factor in the development of 871

805 hyperlipoproteinemia and atherosclerosis [45,46]. Our 872
806 873
807
data also showed no association between the non- 874
Total, direct, and indirect effects of PRS for AD dementia on late-life cognitive function mediated by vascular pathologies

3.2%*
2.7%*

7.4%*
5.6%*

2.1%*

808 19q13-ADPRS and any of the examined vascular pathol- 875

1.6%

3.6%

2.0%
0.9%
PM

809 ogies, despite previously reported associations of non- 876

810 APOE AD risk genes with inflammation and abnormal 877
2.002 (2.007, 2.00004)

2.002 (2.008, 2.0004)

2.001 (2.005, 2.0001)

811 878
2.002 (2.006, 2.001)

2.003 (2.008, 2.001)

2.001 (2.006, .0001)

2.002 (2.005, .0004)

2.001 (2.005, .0003)

lipid metabolism, which are both risk factors for vascular

2.001 (2.004, .001)

812 879
813
disease [47]. Future research with larger samples is 880
needed to test for association between vascular pathol-
Indirect effect

814 881
(95% BCCI)

815 ogies and AD dementia–associated alleles outside of the 882

816 APOE-linkage region. 883
817 884
NOTE. PM: proportion mediated 5 indirect effect b coefficient/total effect b coefficient.

In our sample, we observed associations of the APOE-

818 885
819
ADPRS with both memory and global cognition, whereas 886
2.072 (2.115, 2.023)
2.076 (2.123, 2.032)
2.067 (2.110, 2.022)

2.067 (2.116, 2.020)

2.069 (2.114, 2.021)
2.057 (2.101, 2.012)
2.035 (2.085, .017)
2.041 (2.088, .010)
2.046 (2.093, .002)

820 the non-APOE-ADPRS was associated with memory, but 887

821 not global cognition. A previous meta-analysis including 888
822 77 studies of the association between APOE and cognitive 889
(95% BCCI)
Direct effect

823 function suggested that carriers of APOE-e4 performed 890

824 891
825
worse on multiple domains of cognitive tests, including 892
826 memory, executive functioning, perceptual speed, and 893
2.074 (2.117, 2.025)
2.078 (2.124, 2.033)
2.069 (2.112, 2.023)

2.068 (2.118, 2.022)

2.048 (2.096, 2.001)

2.070 (2.115, 2.022)

2.058 (2.102, 2.013)

827 overall global cognition [48]. On the other hand, the 894
2.038 (2.087, .013)
2.043 (2.091, .007)

828 non-APOE-ADPRS calculated by using summary statis- 895

829 tics from the International Genomics of Alzheimer’s Proj- 896
830 897
(95% BCCI)

ect (IGAP) was found to be associated with memory

Total effect

831 898
Memory

832 impairment but not executive function in nondemented 899

833 subjects, with mean age of 75.3 years, in the Alzheimer’s 900
834 Disease Neuroimaging Initiative (ADNI) [49]. It is 901
2308
2307
2577
2308
2307
2577
2308
2307
2577

835 possible that impaired memory was more likely to be de- 902
Mediator N

836 903
837
tected than deficits in other cognitive domains for individ- 904
uals in the early stage of cognitive decline. However,
WML

WML

WML

838 905
CMB

CMB

Non-19q13-ADPRS CMB
CAC

CAC

CAC

839 more research is needed on the relationship between spe- 906

840 cific genes and different domains of cognitive function. 907
841 Having established a SNP-based genetic overlap be- 908
842 909
19q13-ADPRS

tween AD dementia, vascular pathologies, and late-life

GW-ADPRS

843 910
cognition, we then sought to identify the causal relation-
Predictor

844 911
Table 4

845 ships between ADPRSs, vascular pathologies, and cogni- 912

846 tion scores. Our findings indicate that AD dementia– 913

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914 associated SNPs affect late-life cognition partially through 981

915 pathways involving vascular pathologies, providing insight 982
916 983
917
into potential pathogenic mechanisms in clinical AD demen- 984
918 tia. The results also may lend further support to interventions Q4 985
919 to reduce vascular pathologies, which may be of value in the 986
920 prevention of AD dementia. It is worth noting that we sepa- 987
921 rately examined the mediation effects of CMBs, WMLs, and 988
922 989
923
CAC. Although measures of these vascular pathologies were 990
924 correlated with each other, their correlations were relatively 991
925 weak in our sample (Kendall’s tau-b 5 0.07 for CMB-WML, 992
926 Point-biserial correlation coefficient 5 0.08 for CMB-CAC 993
927 and 0.12 for WML-CAC). Thus, it is reasonable to believe 994
928 995
929
that a certain proportion of AD dementia–associated SNP ef- 996
930 fects on cognitive function was mediated by vascular pathol- 997
931 ogies when considering all vascular mediators together. 998
932 The only previous study investigating the mediation role 999
933 of cerebrovascular imaging markers between genetic vari- 1000
934 1001
935
ants and cognitive function, which used an overlapping sam- 1002
936 ple from the same cohort (the AGES-Reykjavik), reported 1003
937 that about 9% of the total effect of APOE4 carriership on 1004
938 global cognition was mediated by CMB and WML volume 1005
939 together [30]. Our analyses revealed similar but stronger 1006
940 1007
941
mediation effect of vascular pathologies on the relationship 1008
942 between SNPs and cognition. The major strength of the pre- 1009
943 sent study is that we assessed the effects of PRS, aggregating 1010
944 multiple possible risk alleles for AD across the whole 1011
945 genome, within or beyond the APOE-linkage region, 1012
946 1013
947
weighted by their estimated effect sizes. Moreover, we 1014
948 considered both cerebral small-vessel and systemic large- 1015
949 vessel imaging markers, which have been previously associ- 1016
950 ated with dementia or poor cognition, as potential mediators. 1017
951 Several limitations in the present study should be noted. 1018
952 1019
953
In the population-based sample, in which most subjects 1020
954 1021
955 is allowed for in the mediation relationship between 19q13-ADPRS, 1022
956 vascular markers, and memory score. Detailed results of sensitivity analyses 1023
957 of unmeasured confounding for all other mediation analyses are described in 1024
958 Supplementary Results, Table S1, and Figure S3. A: predictor—19q13- 1025
959 ADPRS. M: mediator—(A) CMB, (B) WML, or (C) CAC. Y: outcome— 1026
960 memory score. The y-axis is the proportion mediated. The x-axis, denoted 1027
961 by rho, is the degree of hypothetical unmeasured confounding, estimated 1028
962 by the size of the correlation between the residuals in the equation predicting 1029
963 M and the equation predicting Y. The larger the absolute value of rho, the 1030
964 stronger the confounding. The solid curve shows the estimated proportion 1031
965 mediated for different values of the correlation between the residuals in 1032
966 equations. The shaded part of the plot represents the 95% intervals surround- 1033
967 ing the mediated effect. The x-intercept represents the value of rho at which 1034
968 proportion mediated equals to 0. The horizontal broken line denotes the pro- 1035
969 portion mediated without considering unmeasured confounding. When rho 1036
970 is equal to zero, the reported proportion mediated is the same as that we esti- 1037
971 mated in the mediation analysis without considering unmeasured confound- 1038
972 ing. For other values of rho, the proportion mediated is calculated under 1039
973 different levels of unobserved confounding. When rho ,0, there is unmea- 1040
974 sured confounding associated with better cognition and less severe vascular 1041
975 pathology or unmeasured confounding associated with poorer cognition and 1042
976 Fig. 2. Sensitivity analyses of unmeasured confounding for the relationship more severe vascular pathology (seemly more likely); our estimated propor- 1043
977 between the 19q13-ADPRS and memory score mediated by (A) CMB, (B) tion mediated would underestimate the true mediation effects of vascular Q9 1044
978 WML, or (C) CAC; Figure 2 presents how the proportion mediated would pathologies. Abbreviations: WML, white matter lesion; CAC, coronary ar- 1045
979 change if unmeasured confounding of a specified direction and magnitude tery calcification; CMB, cerebral microbleed. 1046
980 1047

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1048 were cognitively normal or mildly impaired, mean scores of ing organizations or sponsors were involved in study design; 1115
1049 cognitive tests reflect both lifelong cognitive variability and in the collection, analysis, or interpretation of data; in 1116
1050 1117
1051
recent pathological changes, and the former may overwhelm writing of the report; or in the decision to submit the article 1118
1052 the latter. However, with our relatively large sample size, we for publication. 1119
1053 were able to detect small signals and parse these signals into 1120
1054 what appear to be meaningful mediation relationships. Supplementary data 1121
1055 Nonetheless, the sample may have only been large enough 1122
1056 Supplementary data related to this article can be found at 1123
1057
to detect APOE-related signals, even if other causal SNPs 1124
are present. In any event, in the setting of small signals, https://doi.org/10.1016/j.jalz.2018.08.002.
1058 1125
1059 another major limitation is the possible violation of the no- 1126
1060 unmeasured-confounding assumption necessary for causal 1127
1061 mediation analyses. However, our sensitivity analyses sug- RESEARCH IN CONTEXT 1128
1062 1129
1063
gest that given the expected direction of unmeasured con- 1130
1064 founding, our estimated indirect effects may underestimate 1131
1065 the true mediated effects. In addition, the ADPRS, including  Systematic review: A large literature, updated with a 1132
1066 only common genetic variants, cannot account for all the ge- 1133
recent PubMed search, includes extensive epidemio-
1067 netic effects on cognitive performance and AD dementia. 1134
1068 logical and neuropathological evidence suggesting 1135
1069
Although our SNP-based PRSs were strongly associated shared mechanisms between vascular pathologies 1136
1070 with vascular and cognitive phenotypes, and the PRS for and Alzheimer’s disease (AD) dementia. However, 1137
1071 AD dementia has been reported to be capable of capturing few studies have examined their polygenic overlap, 1138
1072 nearly all common genetic risks for AD [50], there are still 1139
and no published research has focused on whether
1073 causal genomic variants (e.g., rare variants) that are not 1140
1074 vascular pathologies mediate the relationship be- 1141
1075
well tagged by GWAS SNPs. However, the genetic effects tween AD-associated genes and late-life cognition. 1142
1076 not captured by SNP-based risk scores can also be seen as 1143
1077 a type of unmeasured mediator-outcome confounding.  Interpretation: Our findings support the hypothesis of 1144
1078 Therefore, the sensitivity analyses mentioned previously a genetic overlap, mostly due to APOE, between AD 1145
1079 may help minimize these concerns. Finally, although our dementia and vascular pathologies. The cumulative 1146
1080 effect of AD-related genes on late-life cognition 1147
1081
use of causal mediation analysis appears to imply mecha- 1148
nistic causality, we note that our design is ultimately corre- was partially but significantly mediated by cerebral
1082 1149
1083 lational. In future research, an experimental-causal-chain microbleeds, white matter lesions, and coronary 1150
1084 approach may help to develop a more fundamental under- calcification, underscoring the potential role of 1151
1085 standing of causal mechanisms. vascular factors in cognitive decline. 1152
1086 1153
1087
This is the first study, to our knowledge, that combined  Future directions: These results should be confirmed 1154
1088 polygenic profiling and causal mediation methods to identify in larger samples. Research is also needed on the rela- 1155
1089 the causal relationship between two genetically correlated tionship of specific genes and pathways with different 1156
1090 phenotypes and their shared genetic factors. Our findings 1157
domains of cognitive function. In the meantime, these
1091 support the hypothesis of a genetic overlap, mostly due to 1158
1092 findings suggest vascular pathologies as a target for 1159
1093
APOE, between AD dementia and vascular pathologies, future mechanistic research on AD. 1160
1094 especially SVDs. Our results also showed that in older indi- 1161
1095 viduals, CMBs, WMLs, and CAC may causally affect cogni- 1162
1096 tive function and partially mediate the polygenic effects of 1163
1097 AD-related genes on cognition, underscoring the potential 1164
1098 1165
1099
role of vascular factors in cognitive decline and suggesting References 1166
1100 vascular pathologies as a target for future mechanistic 1167
1101 research in this area. [1] Toledo JB, Arnold SE, Raible K, Brettschneider J, Xie SX, 1168
1102 Grossman M, et al. Contribution of cerebrovascular disease in autopsy 1169
1103 confirmed neurodegenerative disease cases in the National Alz- 1170
1104 Acknowledgments heimer’s Coordinating Centre. Brain 2013;136:2697–706. Q6 1171
1105 [2] Schneider JA, Bennett DA. Where vascular meets neurodegenerative 1172
1106 The authors thank all the participants of the AGES- disease. Stroke 2010;41:S144–6. 1173
1107 Reykjavik Study and the Icelandic Heart Association clinic [3] Vernooij MW, van der Lugt A, Ikram MA, Wielopolski PA, 1174
1108 staff for their invaluable contributions. Niessen WJ, Hofman A, et al. Prevalence and risk factors of cerebral 1175
1109 Study funding: The AGES-Reykjavik Study was funded by microbleeds: The Rotterdam Scan Study. Neurology 2008; 1176
Q5
1110 70:1208–14. 1177
1111
the NIH [contract N01-AG-12100]; the Intramural Research 1178
[4] Goos JD, Kester MI, Barkhof F, Klein M, Blankenstein MA,
1112 Program of the National Institute on Aging and the National Scheltens P, et al. Patients with Alzheimer disease with multiple mi- 1179
1113 Eye Institute [ZIAEY000401], NIH; and the Icelandic Heart crobleeds: Relation with cerebrospinal fluid biomarkers and cognition. 1180
1114 Association and the Icelandic Parliament. None of the fund- Stroke 2009;40:3455–60. 1181

FLA 5.5.0 DTD
JALZ2738_proof
18 September 2018
8:53 pm
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 10 Y.-F. Lin et al. / Alzheimer’s & Dementia - (2018) 1-11

1182 [5] Qiu C, Cotch MF, Sigurdsson S, Jonsson PV, Jonsdottir MK, [25] Sveinbjornsdottir S, Sigurdsson S, Aspelund T, Kjartansson O, 1249
1183 Sveinbjrnsdottir S, et al. Cerebral microbleeds, retinopathy, and de- Eiriksdottir G, Valtysdottir B, et al. Cerebral microbleeds in the pop- 1250
1184 mentia: The AGES-Reykjavik Study. Neurology 2010;75:2221–8. ulation based AGES-Reykjavik study: Prevalence and location. J Neu- 1251
1185 [6] Greenberg SM, Vernooij MW, Cordonnier C, Viswanathan A, Al- rol Neurosurg Psychiatry 2008;79:1002–6. 1252
1186 Shahi Salman R, Warach S, et al. Cerebral microbleeds: A guide to [26] Schellenberg GD, Montine TJ. The genetics and neuropathology of 1253
1187 detection and interpretation. Lancet Neurol 2009;8:165–74. Alzheimer’s disease. Acta Neuropathol 2012;124:305–23. 1254
1188 [7] Cordonnier C, van der Flier WM. Brain microbleeds and Alzheimer’s [27] Desikan RS, Schork AJ, Wang Y, Thompson WK, Dehghan A, 1255
1189 disease: Innocent observation or key player? Brain 2011;134:335–44. Ridker PM, et al. Polygenic overlap between C-Reactive protein, 1256
1190 [8] Inaba M, White L, Bell C, Chen R, Petrovitch H, Launer L, et al. White plasma lipids, and Alzheimer disease. Circulation 2015; 1257
1191 matter lesions on brain magnetic resonance imaging scan and 5-year 131:2061–9. 1258
1192 cognitive decline: The Honolulu-Asia aging study. J Am Geriatr Soc [28] Traylor M, Adib-Samii P, Harold D, Alzheimer’s Disease Neuroimag- 1259
1193 2011;59:1484–9. ing I, International Stroke Genetics Consortium, UKYLSDNAr, 1260
1194 [9] Prins ND, van Dijk EJ, den Heijer T, Vermeer SE, Koudstaal PJ, Dichgans M, et al. Shared genetic contribution to Ischaemic Stroke 1261
1195 Oudkerk M, et al. Cerebral white matter lesions and the risk of demen- and Alzheimer’s Disease. Ann Neurol 2016. Q7 1262
1196 tia. Arch Neurol 2004;61:1531–4. [29] Liu G, Yao L, Liu J, Jiang Y, Ma G, Genetic, et al. Cardiovascular 1263
1197 [10] Debette S, Markus HS. The clinical importance of white matter hyper- disease contributes to Alzheimer’s disease: evidence from large- 1264
1198 intensities on brain magnetic resonance imaging: Systematic review scale genome-wide association studies. Neurobiol Aging 2014; 1265
1199 and meta-analysis. BMJ 2010;341:c3666. 35:786–92. 1266
1200 [11] de Jong FJ, Schrijvers EM, Ikram MK, Koudstaal PJ, de Jong PT, [30] Sajeev G. Mediation Analysis in Understanding Mechanism of Alz- 1267
1201 Hofman A, et al. Retinal vascular caliber and risk of dementia: The heimer’s Disease Risk 2015. Boston: Harvard T.H. Chan School of 1268
1202 Rotterdam study. Neurology 2011;76:816–21. Public Health; 2015. 1269
1203 [12] Ikram MK, De Jong FJ, Van Dijk EJ, Prins ND, Hofman A, [31] Harris TB, Launer LJ, Eiriksdottir G, Kjartansson O, Jonsson PV, 1270
1204 Breteler MM, et al. Retinal vessel diameters and cerebral small vessel Sigurdsson G, et al. Age, Gene/Environment Susceptibility- 1271
1205 disease: The Rotterdam Scan Study. Brain 2006;129:182–8. Reykjavik Study: Multidisciplinary applied phenomics. Am J Epide- 1272
1206 [13] Ikram MK, de Jong FJ, Vernooij MW, Hofman A, Niessen WJ, van der miol 2007;165:1076–87. 1273
1207 Lugt A, et al. Retinal vascular calibers associate differentially with ce- [32] Naj AC, Jun G, Beecham GW, Wang LS, Vardarajan BN, Buros J, et al. 1274
1208 rebral gray matter and white matter atrophy. Alzheimer Dis Assoc Dis- Common variants at MS4A4/MS4A6E, CD2AP, CD33 and EPHA1 1275
1209 ord 2013;27:351–5. are associated with late-onset Alzheimer’s disease. Nat Genet 2011; 1276
1210 [14] de la Torre JC. Vascular risk factor detection and control may prevent 43:436–41. 1277
1211 Alzheimer’s disease. Ageing Res Rev 2010;9:218–25. [33] VanderWeele TJ. Mediation analysis: A practitioner’s guide. Annu 1278
1212 [15] Sabayan B, van Buchem MA, Sigurdsson S, Zhang Q, Meirelles O, Rev Public Health 2016;37:17–32. 1279
1213 Harris TB, et al. Cardiac and Carotid Markers Link With Accelerated [34] Robins JM, Greenland S. Identifiability and exchangeability for direct 1280
1214 Brain Atrophy: The AGES-Reykjavik Study (Age, Gene/Environment and indirect effects. Epidemiology 1992;3:143–55. 1281
1215 Susceptibility-Reykjavik). Arterioscler Thromb Vasc Biol 2016; [35] Emsley R, Liu H. PARAMED: Stata Module to Perform Causal Medi- 1282
1216 36:2246–51. ation Analysis Using Parametric Regression Models 2013. Boston 1283
1217 [16] van Oijen M, de Jong FJ, Witteman JC, Hofman A, Koudstaal PJ, College Department of Economics; 2013. 1284
1218 Breteler MM. Atherosclerosis and risk for dementia. Ann Neurol [36] Poels MM, Ikram MA, van der Lugt A, Hofman A, Niessen WJ, 1285
1219 2007;61:403–10. Krestin GP, et al. Cerebral microbleeds are associated with worse 1286
1220 [17] Wendell CR, Waldstein SR, Ferrucci L, O’Brien RJ, Strait JB, cognitive function: The Rotterdam Scan Study. Neurology 2012; 1287
1221 Zonderman AB. Carotid atherosclerosis and prospective risk of de- 78:326–33. 1288
1222 mentia. Stroke 2012;43:3319–24. [37] Staals J, Booth T, Morris Z, Bastin ME, Gow AJ, Corley J, et al. Total 1289
1223 [18] Bos D, Vernooij MW, Elias-Smale SE, Verhaaren BF, Vrooman HA, MRI load of cerebral small vessel disease and cognitive ability in older 1290
1224 Hofman A, et al. Atherosclerotic calcification relates to cognitive func- people. Neurobiol Aging 2015;36:2806–11. 1291
1225 tion and to brain changes on magnetic resonance imaging. Alzheimers [38] Yates PA, Villemagne VL, Ellis KA, Desmond PM, Masters CL, 1292
1226 Dement 2012;8:S104–11. Rowe CC. Cerebral microbleeds: A review of clinical, genetic, and 1293
1227 [19] Reis JP, Launer LJ, Terry JG, Loria CM, Zeki Al Hazzouri A, Sidney S, neuroimaging associations. Front Neurol 2014;4:205. 1294
1228 et al. Subclinical atherosclerotic calcification and cognitive func- [39] Smith EE, Nandigam KR, Chen YW, Jeng J, Salat D, Halpin A, et al. 1295
1229 tioning in middle-aged adults: The CARDIA study. Atherosclerosis MRI markers of small vessel disease in lobar and deep hemispheric 1296
1230 2013;231:72–7. intracerebral hemorrhage. Stroke 2010;41:1933–8. 1297
1231 [20] Vidal JS, Sigurdsson S, Jonsdottir MK, Eiriksdottir G, Thorgeirsson G, [40] Jellinger KA. Alzheimer disease and cerebrovascular pathology: An 1298
1232 Kjartansson O, et al. Coronary artery calcium, brain function and update. J Neural Transm (vienna) 2002;109:813–36. 1299
1233 structure: The AGES-Reykjavik Study. Stroke 2010;41:891–7. [41] Esiri M, Chance S, Joachim C, Warden D, Smallwood A, Sloan C, 1300
1234 [21] Michaelson DM. APOE epsilon4: The most prevalent yet understudied et al. Cerebral amyloid angiopathy, subcortical white matter disease 1301
1235 risk factor for Alzheimer’s disease. Alzheimers Dement 2014; and dementia: Literature review and study in OPTIMA. Brain Pathol 1302
1236 10:861–8. 2015;25:51–62. 1303
1237 [22] Schilling S, DeStefano AL, Sachdev PS, Choi SH, Mather KA, [42] Pfeifer LA, White LR, Ross GW, Petrovitch H, Launer LJ. Cerebral 1304
1238 DeCarli CD, et al. APOE genotype and MRI markers of cerebrovascu- amyloid angiopathy and cognitive function: the HAAS autopsy study. 1305
1239 lar disease: Systematic review and meta-analysis. Neurology 2013; Neurology 2002;58:1629–34. 1306
1240 81:292–300. [43] de Leeuw FE, de Groot JC, Oudkerk M, Witteman JC, Hofman A, van 1307
1241 [23] Bennet AM, Di Angelantonio E, Ye Z, Wensley F, Dahlin A, Gijn J, et al. Hypertension and cerebral white matter lesions in a pro- 1308
1242 Ahlbom A, et al. Association of apolipoprotein E genotypes with lipid spective cohort study. Brain 2002;125:765–72. 1309
1243 levels and coronary risk. JAMA 2007;298:1300–11. [44] Liu W, Zhang Y, Yu CM, Ji QW, Cai M, Zhao YX, et al. Current un- 1310
1244 [24] Khan TA, Shah T, Prieto D, Zhang W, Price J, Fowkes GR, et al. Apoli- derstanding of coronary artery calcification. J Geriatr Cardiol 2015; 1311
1245 poprotein E genotype, cardiovascular biomarkers and risk of stroke: 12:668–75. 1312
1246 systematic review and meta-analysis of 14,015 stroke cases and pooled [45] Tai LM, Thomas R, Marottoli FM, Koster KP, Kanekiyo T, Morris AW, 1313
1247 analysis of primary biomarker data from up to 60,883 individuals. Int J et al. The role of APOE in cerebrovascular dysfunction. Acta Neuro- 1314
1248 Epidemiol 2013;42:475–92. pathol 2016;131:709–23. 1315

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1316 [46] Huang Y, Mahley RW. Apolipoprotein E: structure and function in [49] Mormino EC, Sperling RA, Holmes AJ, Buckner RL, De 1383
1317 lipid metabolism, neurobiology, and Alzheimer’s diseases. Neurobiol Jager PL, Smoller JW, et al. Polygenic risk of Alzheimer disease 1384
1318 Dis 2014;72 Pt:3–12. is associated with early- and late-life processes. Neurology 2016; 1385
1319 [47] Karch CM, Goate AM. Alzheimer’s disease risk genes and mecha- 87:481–8. 1386
1320 nisms of disease pathogenesis. Biol Psychiatry 2015;77:43–51. [50] Escott-Price V, Shoai M, Pither R, Williams J, Hardy J. Poly- 1387
1321 [48] Wisdom NM, Callahan JL, Hawkins KA. The effects of apolipoprotein genic score prediction captures nearly all common genetic 1388
1322 E on non-impaired cognitive functioning: a meta-analysis. Neurobiol risk for Alzheimer’s disease. Neurobiol Aging 2017;49:214.e7. 1389
1323 Aging 2011;32:63–74. 214.e11. 1390
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