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Toward defining the preclinical stages of Alzheimer’s disease: Recommendations from the National Institute on Aging-Alzheimer’s Association workgroups on diagnostic guidelines for Alzheimer’s disease
Open accessAbstract
The pathophysiological process of Alzheimer's disease (AD) is thought to begin many years before the diagnosis of AD dementia. This long “preclinical” phase of AD would provide a critical opportunity for therapeutic intervention; however, we need to further elucidate the link between the pathological cascade of AD and the emergence of clinical symptoms. The National Institute on Aging and the Alzheimer's Association convened an international workgroup to review the biomarker, epidemiological, and neuropsychological evidence, and to develop recommendations to determine the factors which best predict the risk of progression from “normal” cognition to mild cognitive impairment and AD dementia. We propose a conceptual framework and operational research criteria, based on the prevailing scientific evidence to date, to test and refine these models with longitudinal clinical research studies. These recommendations are solely intended for research purposes and do not have any clinical implications at this time. It is hoped that these recommendations will provide a common rubric to advance the study of preclinical AD, and ultimately, aid the field in moving toward earlier intervention at a stage of AD when some disease‐modifying therapies may be most efficacious.
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“The susceptibility of the conventional criteria for MCI to diagnostic error is likely to be amplified if used to characterize and stage preclinical AD—a pre-MCI categorization based on subtle cognitive decline [8].”
From Neuropsychological Criteria for Mild Cognitive Impairment Improves Diagnostic Precision, Biomarker Associations, and Progression Rates (2014) · cites this paper as [8]
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
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“In PET imaging, PIB and Florbetapir (AV45) amyloid tracers have shown greater cortical uptake in patients diagnosed with AD compared with control participants 11,57 .”
From OASIS-3: Longitudinal Neuroimaging, Clinical, and Cognitive Dataset for Normal Aging and Alzheimer Disease (2019) · cites this paper as [11]
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“Several anti-Aβ therapeutic strategies are being pursued to treat AD; however, it is likely that treatment will need to begin during the preclinical phase to prevent or limit plaque accumulation to be beneficial in reducing the risk of developing AD (51, 52).”
From Serotonin signaling is associated with lower amyloid-β levels and plaques in transgenic mice and humans (2011) · cites this paper as [52]
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“New clinical diagnostic consensus criteria have now been finalized under the auspices of the NIA and Alzheimer's Association (52), with novel features including recognition of a preclinical stage of AD and the incorporation of imaging and laboratory-based cerebrospinal fluid biomarkers.”
From Accuracy of the Clinical Diagnosis of Alzheimer Disease at National Institute on Aging Alzheimer Disease Centers, 2005–2010 (2012) · cites this paper as [52]
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“Alzheimer’s disease (AD) begins several decades before the clinical onset of dementia with progressive amyloid accumulation preceding significant tau pathology and neurodegeneration.10,11”
From Machine learning reveals prominent spontaneous behavioral changes and treatment efficacy in humanized and transgenic Alzheimer's disease models (2024) · cites this paper as [11]
Experimental — accuracy not yet measured
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In the citing paper
“Because there is evidence that the pathophysiology of AD likely begins many years before the emergence of clinical symptoms or a syndrome such as MCI or dementia”
From The Need to Separate Chronic Traumatic Encephalopathy Neuropathology from Clinical Features (2017) · cites this paper as [102]
The cited source says what the claim attributes to it.
In the citing paper
“Nevertheless, after decades of research, both the etiology and the pathophysiologic sequence of AD remain uncertain [102]”
From The Need to Separate Chronic Traumatic Encephalopathy Neuropathology from Clinical Features (2017) · cites this paper as [102]
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“This unifying research framework is a natural descendant of the 2011 NIA-AA preclinical AD recommendations that were based on the concept that AD, identified by biomarkers, can exist in the absence of symptoms [4].”
From NIA‐AA Research Framework: Toward a biological definition of Alzheimer's disease (2018) · cites this paper as [4]
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In the citing paper
“Clinico-pathologic correlations for individuals without cognitive impairment should indicate that it is possible for AD neuropathologic change to predate onset of symptoms by years [54].”
From National Institute on Aging–Alzheimer’s Association guidelines for the neuropathologic assessment of Alzheimer’s disease: a practical approach (2012) · cites this paper as [54]
The cited source says what the claim attributes to it.
In the citing paper
“recognition that AD neuropathologic changes may occur in the apparent absence of cognitive impairment”
From National Institute on Aging–Alzheimer’s Association guidelines for the neuropathologic assessment of Alzheimer’s disease: a practical approach (2012) · cites this paper as [54]
The cited source says what the claim attributes to it.
In the citing paper
“This later point is important as the pathophysiological changes in the brain of people with AD require several years to occur.16”
From Cumulative Use of Strong Anticholinergics and Incident Dementia: A Prospective Cohort Study (2015) · cites this paper as [16]
The cited source says what the claim attributes to it.
In the citing paper
“The timing of therapeutic treatment in AD seems to be crucial as studies have shown that treating the disease too late has little efficacy (Sperling et al., 2011; Yiannopoulou et al., 2019).”
From Inhibiting USP16 rescues stem cell aging and memory in an Alzheimer’s model (2022) · cites this paper as Sperling et al., 2011
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“But their high cost and insufficient accessibility are being major limitations [12].”
From Integrated analysis of ultra-deep proteomes in cortex, cerebrospinal fluid and serum reveals a mitochondrial signature in Alzheimer’s disease (2020) · cites this paper as [12]
Experimental — accuracy not yet measuredIn the citing paper
“individuals remain cognitively normal for many years despite accumulating aggregates of Aβ plaques and tau neurofibrillary tangles (Sperling et al., 2011).”
From A Multi-network Approach Identifies Protein-Specific Co-expression in Asymptomatic and Symptomatic Alzheimer’s Disease (2017) · cites this paper as Sperling et al., 2011
In the citing paper
“The neuropathological changes of Alzheimer’s disease (AD) begin two decades or more before signs of cognitive impairment (Sperling et al., 2011).”
From A Multi-network Approach Identifies Protein-Specific Co-expression in Asymptomatic and Symptomatic Alzheimer’s Disease (2017) · cites this paper as Sperling et al., 2011
In the citing paper
“Additionally, we used the old criteria for the preclinical AD definition, while the recent research criteria also require tau positivity [8].”
From Duration of preclinical, prodromal, and dementia stages of Alzheimer's disease in relation to age, sex, and APOE genotype (2019) · cites this paper as [8]
In the citing paper
“Plaque formation rates also vary over time [217]. After a period of rapid accumulation, plaque deposition gradually slows and by the time symptoms manifest plaque deposition is essentially done [20, 205, 218].”
From The Alzheimer’s disease mitochondrial cascade hypothesis: progress and perspectives (2014) · cites this paper as [20]
In the citing paper
“The amyloid cascade hypothesis [14, 15], in conjunction with the newly designated preclinical AD category [20], necessarily infers cognitive changes that arise before plaques appear are etiologically unrelated to cognitive changes that arise after plaques appear.”
From The Alzheimer’s disease mitochondrial cascade hypothesis: progress and perspectives (2014) · cites this paper as [20]
In the citing paper
“In addition to using Aβ phenomena to distinguish AD from “normal” brain aging, the new criteria make one critical mechanistic assumption. Aβ is identified as an “upstream” AD biomarker [77]. Other biomarkers, including increased CSF tau, CSF phospho-tau, and decreased glucose utilization (as demonstrated by fluorodeoxyglucose PET; FDG PET), are identified as “downstream” biomarkers.”
From Brain aging, Alzheimer's disease, and mitochondria (2011) · cites this paper as [77]
In the citing paper
“According to the new AD diagnostic criteria cognitive decline and an absence of alternative dementia-associated pathology are no longer required features. At least for research purposes, to qualify for a diagnosis of AD altered brain or CSF Aβ is now the sole requirement [77].”
From Brain aging, Alzheimer's disease, and mitochondria (2011) · cites this paper as [77]
In the citing paper
“This is reflected by the recent adoption of AD diagnostic criteria that classify cognitively normal individuals with brain plaques or low cerebrospinal fluid Aβ levels as having “preclinical AD” [77].”
From Brain aging, Alzheimer's disease, and mitochondria (2011) · cites this paper as [77]
In the citing paper
“Studies of non-demented elderly cohorts overall report approximately 20–40% are PIB-positive [67, 68, 71–78].”
From Brain aging, Alzheimer's disease, and mitochondria (2011) · cites this paper as [77]
In the citing paper
“According to the new criteria, the primary dividing line between AD and brain aging is the presence or absence of brain or CSF Aβ changes.”
From Brain aging, Alzheimer's disease, and mitochondria (2011) · cites this paper as [77]
In the citing paper
“This asymptomatic phase of AD (AsymAD) is currently considered a preclinical stage of the disease [27, 28].”
From Deep proteomic network analysis of Alzheimer’s disease brain reveals alterations in RNA binding proteins and RNA splicing associated with disease (2018) · cites this paper as [28]
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Metadata
- Authors
- Sperling, R. A., Aisen, P. S., Beckett, L. A., Bennett, D. A., Craft, S., Fagan, A. M., Iwatsubo, T., Jack, C. R., Kaye, J., Montine, T. J., Park, D. C., Reiman, E. M., Rowe, C. C., Siemers, E., Stern, Y., Yaffe, K., Carrillo, M. C., Thies, B., Morrison‐Bogorad, M., Wagster, M. V., & Phelps, C. H.
- Affiliations
- Brigham and Women's Hospital (US)
- University of California San Diego (US)
- University of California, Davis (US)
- Rush University Medical Center (US)
- University of Washington (US)
- Washington University in St. Louis (US)
- The University of Tokyo (JP)
- Mayo Clinic (US)
- Oregon Health & Science University (US)
- The University of Texas at Dallas (US)
- Banner Alzheimer’s Institute (US)
- The University of Melbourne (AU)
- Eli Lilly (United States) (US)
- Columbia University Irving Medical Center (US)
- San Francisco VA Medical Center (US)
- Alzheimer's Association Chicago IL USA
- Alzheimer's Association (US)
- National Institutes of Health (US)
- Corresponding author
- Sperling, Reisa A.
- ORCID
- Venue
- Alzheimer's & Dementia
- Publisher
- Wiley
- Published
- 2011-04-22
- Volume
- 7
- Issue
- 3
- Pages
- 280-292
- ISSN
- 1552-5260 (ISSN-L)
- 1552-5279
- PMC
- PMC3220946
- OpenAlex
- W2129497119
- Semantic Scholar
- 4718e61de2c928d77780b2a72fac704f18d8297b
- Cited by
- 7,155
- References
- 71
- Citations by year
- 2026: 375 · 2025: 467 · 2024: 485 · 2023: 445 · 2022: 534 · 2021: 575 · 2020: 550 · 2019: 533 · 2018: 513 · 2017: 471 · 2016: 468 · 2015: 461 · 2014: 417 · 2013: 418 · 2012: 302
- FWCI
- 277.90
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Alzheimer s & Dementia (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- Columbia Academic Commons (Columbia University)
- Funders
- National Institute on Aging
- Pfizer
- Baxter International
- Johnson and Johnson
- Eli Lilly and Company
- Bayer
- Topics
- Health Sciences › Medicine › Psychiatry and Mental health › Dementia and Cognitive Impairment Research
- Life Sciences › Neuroscience › Cellular and Molecular Neuroscience › Alzheimer's disease research and treatments
- Health Sciences › Medicine › Oncology › Cancer-related cognitive impairment studies
- Keywords
- Alzheimer's disease, preclinical Alzheimer's disease
- MeSH terms
- Alzheimer Disease, Cognition Disorders, Humans, United States, Biomarkers, Practice Guidelines as Topic, National Institute on Aging (U.S.)
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Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
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