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Abstract Background Self‐administered and remote digital cognitive assessments provide a scalable method for screening and longitudinal cognitive monitoring. Mayo Test Drive (MTD) is one such assessment with previously demonstrated usability, reliability, validity and multi‐device compatibility. MTD includes a computer‐adaptive word list memory test (Stricker Learning Span) and a measure of processing speed/executive functioning (Symbols Test) that combine to provide an MTD Composite. This study aimed to develop a conditional normative model predicting longitudinal cognitive change for MTD, and to validate the model in two independent samples of cognitively unimpaired (CU) and mild cognitive impairment (MCI)/dementia (DEM) participants. Method 1355 CU participants at initial MTD assessment with 2‐4 consecutive MTD assessments every 7.5 months comprised the development dataset. Linear mixed effects models were used to construct a conditional normative model for MTD assessments 2‐4. The baseline model was chosen a priori , consisting of age, sex, education, baseline score, number of assessments, and time. Device type, race, and baseline score by time interactions were also considered. Variables were only added if a >1% increment in r‐squared was observed. The models were externally validated in 113 CU and 51 MCI/DEM patients. Following model development, the data were updated and additional follow‐up MTD assessments were added for many participants, including the addition of additional CU validation data at test 3 ( N = 126) and 4 ( N = 279). T‐tests compared observed and predicted differences and residual z‐scores between development and validation at each follow‐up assessment. Result Table 1 presents demographic variables. No additional variables increased the r‐squared by >1%. The final models are presented in Table 2. Age, baseline score, sex, and education were significant. Residual z‐scores were not significantly different between CU development and CU validation cohorts, indicating observed scores were in line with model predicted scores. Residual z‐scores were significantly worse among MCI/DEM compared to CU development in 11/12 comparisons (Figure 1), indicating observed scores were below model predicted expectations and implying sensitivity to longitudinal cognitive decline. Conclusion These longitudinal normative models can be used to identify individuals with follow‐up scores outside of expected predicted ranges, signifying abnormal longitudinal cognitive decline.

Abstract Background In addition to visuospatial and visuoperceptual deficits, most PCA patients also report deficits in visual attention, episodic memory, and working memory. The dorsal attention network is known to play a critical role in modulating these clinical functions. However, little is known about the relationship of the dorsal attention network with other core networks and relationships to volume loss and memory functions in PCA. Method Fifty‐seven PCA patients were recruited by the Neurodegenerative Research group, Mayo Clinic, and compared to 60 cognitively unimpaired (CU) individuals from the Mayo Clinic Study of Aging. The CONN functional connectivity toolbox was used to calculate within‐ and between‐network connectivity. Functional connectivity within the key regions (i.e., inter‐hemisphere connectivity) of the dorsal attention network, namely frontal eye field (FEF) and intraparietal sulcus (IPS), and the entire network was generated. Functional connectivity between the dorsal attention network and the frontoparietal, visual, and default mode networks (DMN) were also generated using CONN's network parcellation atlas. Multivariate linear regression models were fit i) to compare within‐ and between‐network connectivity between both groups and ii) to assess relationships between within‐network connectivity and both gray matter volumes and clinical test scores. Result PCA showed reduced within‐network connectivity in the dorsal attention network, specifically within the IPS and the entire network compared to CU. An increase in between‐network connectivity between the frontoparietal network and both FEF and the entire dorsal attention network was noted in PCA compared to CU (Figure 1). Lower dorsal attention within‐network connectivity was associated with a trend for lower volumes in the entire network (Figure 2) and significantly lower scores on the auditory verbal learning test‐recognition percent correct (AVLT‐RCP) and Wechsler Memory Scale (WMS) III‐digit span backward in PCA (Figure 3). Conclusion These findings suggest that within‐ and between‐network connectivity of the dorsal attention network, both within key regions and the entire network, was disrupted in PCA patients. However, this network did not show disrupted connectivity with the core PCA networks. Within‐network connectivity disruptions in the dorsal attention network are associated with aspects of memory function, and to some extent, with volume loss.

Abstract Background Aging and dementia are generally associated with lower metabolism in gray matter on FDG‐PET and have been widely studied. However, white matter (WM) metabolic changes remain understudied. We investigated the metabolic changes in WM associated with aging and dementia and their relationships with established Alzheimer's Disease (AD) biomarkers and cognitive outcomes. Method We analyzed data from 3,169 participants (72 ± 9 years; 53% male; 65% cognitively unimpaired) enrolled in the Mayo Clinic Study of Aging (MCSA) and the Alzheimer's Disease Neuroimaging Initiative (ADNI). All participants underwent baseline MRI, amyloid‐PET, and FDG‐PET scans, as well as neuropsychological evaluations, with at least one clinical follow‐up. Voxel‐wise multiple regression analysis identified WM metabolic changes associated with global cognition in cognitively unimpaired MCSA participants ( n = 1,754). Univariate analyses and structural equation models were applied to elucidate the driving factors underlying the WM metabolic changes in MCSA data. Multiple regression and linear mixed‐effects models evaluated the explanatory utility of WM metabolism for baseline global cognition and cognitive decline in both cohorts. In a subset of MCSA participants, we evaluated neurite density index from diffusion MRI as a surrogate of WM health and glial fibrillary acidic protein (GFAP) as a surrogate of neuroinflammation to understand underlying mechanisms. Result We identified an atypical WM signature (AWM‐Signature) in the anterior and superior corona radiata, where glucose metabolism increased as cognitive performance worsened (Figure 1). Hypermetabolism in AWM‐Signature was related to increased age, amyloidosis, vascular disease, and neuroinflammation, as well as decreasing WM neurite density in the same regions (Figure 2). Hypermetabolism in AWM‐Signature regions predicted faster future cognitive decline, even after accounting for demographics, amyloid, and vascular disease metrics. The results observed in the AWM‐Signature regions were consistently in the opposite direction of the associations seen with gray matter and typical WM regions. Conclusion We found unexpected metabolism increases in corona radiata, a hub that carries significant portion of the brain's neural traffic, with aging and disease which likely indicates a compensatory response. These changes may be useful cognitive resilience measures and require further investigation to understand their role in maintaining cognitive function.

Abstract Background Chronic disease conditions lead to brain changes elevating dementia risk. We hypothesized that tissue microstructural changes caused by type 2 diabetes mellitus (T2DM) and hypertension could be effectively captured using an advanced diffusion MRI technique, Neurite Orientation Dispersion and Density Imaging (NODDI). Our goal was to evaluate the usefulness of composite NODDI scores, customized for increased hemoglobin (Hb) A1c and systolic blood pressure as predictors of cognition and compare their performance to other measures typically used to assess dementia risk. Method We collected multi‐shell diffusion MR on 1024 Mayo Clinic Study of Aging participants. NODDI measures (neurite density index (NDI), orientation dispersion index (ODI), and free water fraction (FWF)) in gray matter (GM) and white matter (WM) regions were estimated. To identify brain regions susceptible to both conditions, a multiple linear regression model was fitted for each NODDI metric, using hemoglobin (Hb) A1c (in N = 305 participants) or systolic blood pressure ( N = 906) as predictor, with age, sex, and body mass index (BMI) as covariates. Event‐based modeling was performed with the identified NODDI metrics to investigate the chronological pattern along the course of chronic condition development from this cross‐sectional dataset. Composite metrics were created as a weighted sum of susceptible NODDI metrics. We evaluated the impact of both conditions on cognition using gradient boosting models incorporating composite metrics, additional brain measurements, and demographics. Result Increased HbA1c impacts both GM and WM NODDI relatively evenly, whereas increased systolic blood pressure related NODDI changes were mainly seen in WM (data not shown). With increased HbA1c, the earliest changes were observed in GM ODI, followed by changes in the pons and cortical FWF (Figure 1A). With increased systolic blood pressure, the earliest changes occurred in association fibers and middle cerebellar peduncle, followed by FWF change in lobar and projection WM fibers (Figure 1B). Average feature importance from 100 gradient boosting models for cognition prediction suggests that diabetes‐induced GM changes play a moderately important role in cognitive decline (Figure 2). Conclusion Chronic medical conditions, especially T2DM, result in brain changes that are captured by NODDI and contribute moderately to cognitive performance.

Abstract Background Clinically available plasma p ‐tau217 assays may be utilized in the determination of eligibility for amyloid‐lowering therapies. Our institution recently introduced a plasma p ‐tau217 assay in clinical practice using a two‐cutpoint approach that optimizes the accuracy while minimizing false positive risk and categorizing ≤20% of results as intermediate. In this study, we prospectively evaluate the performance of a plasma p ‐tau217 assay for detection of amyloid pathology using these predefined cutpoints. Method Patients recruited were being considered for lecanemab therapy at a tertiary care subspecialty clinic. Plasma p ‐tau217 was measured using the clinically available Fujirebio Lumipulse p ‐tau217 assay at Mayo Clinic, and results (pg/mL) were classified as either negative (≤0.185), intermediate (0.186–0.324) or positive (≥0.325). Amyloid pathology was determined by amyloid‐PET and/or CSF p ‐tau181/Aβ42. Result Ninety‐three patients were recruited between November 2023 and December 2024. Of these, 49 underwent amyloid‐PET, 4 had CSF p ‐tau181/Aβ42 measurements, and 40 had both PET and CSF results (with 3/40 discordant cases), for use in the assessment of amyloid pathology. The three discordant cases were considered amyloid positive for purposes of plasma p ‐tau217 comparison. Overall amyloid positivity was 90%. Plasma p ‐tau217 results were positive in 83% (77/93), negative in 6% (6/93), and intermediate in 11% (10/93) of patients. An elevated p ‐tau217 predicted the presence of amyloid positivity with a diagnostic accuracy of 96% (95% CI 90% − 99%). In the intermediate range, 80% of patients were positive for amyloid pathology. In patients with a definitive p ‐tau217 result (positive or negative), the positive and negative predictive values were 97% and 83%. There were three patients with discordant results: one PET+/p‐tau217‐, one PET‐/p‐tau217+, and one CSF‐/p‐tau217+. Clinical presentation of these discordant cases was examined, and relevant findings will be discussed. Conclusion The Lumipulse plasma p ‐tau217 assay exhibited acceptable diagnostic accuracy for the determination of amyloid pathology when compared to either amyloid‐PET or CSF p ‐tau181/Aβ42. This prospective study confirms the utility a two‐cutpoint approach for interpreting plasma p ‐tau217 for the assessment of amyloid pathology eligibility for amyloid‐lowering therapies in a heterogenous clinical cohort.

Abstract Background Individuals with coexisting Alzheimer's disease (AD) and disorders of CSF dynamics such as normal‐pressure hydrocephalus (NPH) have lower CSF Aβ42 levels, which can confound interpretation of AD CSF‐biomarkers. However, little is known about how CSF dynamics influences plasma AD biomarkers. The objective of this study was to determine whether mass spectrometry‐based blood tests for AD are associated with disproportionately enlarged subarachnoid space hydrocephalus (DESH) on MRI. Method 509 Individuals from the Mayo Clinic Study of Aging, with MRI, 11C‐Pittsburgh compound B (Aβ) PET scans, and plasma phosphorylated‐tau protein 217, Aβ40 and Aβ42 were included. We performed an age‐adjusted logistic regression to determine whether abnormal values of p ‐Tau 217 (Abnormal if >1.55 pg/mL), %p‐tau217 defined as the ratio of phosphorylated Tau217 to non‐phosphorylated tau x 100% (Abnormal if >1.55%), Aβ42 (Abnormal if <41.5 pg/mL), and Aβ42/40 ratio (Abnormal if <0.094) were associated with the presence of DESH, as classified by a previously validated automated algorithm. Result Thirty‐two participants were classified as DESH‐positive. The median [IQR] age was 76.8 yrs [70.6, 82.9] for participants with DESH and 72.4 [59.3, 85.5] without DESH (Table 1). An abnormal plasma Aβ42 was associated with DESH (OR, 2.56 [1.19, 5.74], p = 0.018), but having an abnormal Aβ42/40 ratio (OR 2.01 [0.94, 4.56], p = 0.079) was not. There was no association between being DESH‐positive and an abnormal plasma p ‐tau217 (OR 1.30 [0.51, 3.09], p = 0.560) or with abnormal %plasma p ‐tau217 (OR 1.82 [0.74, 4.20], p = 0.17) (Figure 1). Subgroup analysis showed that only those participants who had an abnormal Aβ42 and positive amyloid PET (≥25 Centiloids) showed an association with DESH compared to biomarker‐ and PET‐negative participants (OR 3.10 [1.15, 8.43], p = 0.024 ) . Conclusion Understanding how CSF dynamics affect plasma biomarkers is critical for implementation. The relationship between lower Aβ42 and DESH is expected based on prior CSF studies, which can be addressed by using an amyloid ratio. p ‐tau217 shows robustness against DESH, making it a suitable biomarker in cases of abnormal cerebrospinal fluid dynamics although validation in a more severe CSF dynamics group is warranted.

Abstract Background Anti‐amyloid therapy trials have reported changes in some Alzheimer's disease (AD) blood biomarkers (BBMs) suggesting that these BBMs may be useful minimally invasive measures of amyloid clearance and treatment outcomes. However, a better understanding of how AD BBMs changes at the individual level reflect treatment response in relation to other relevant clinical endpoints is necessary before they can be adopted for treatment monitoring. Here, several AD BBMs were assessed longitudinally in patients undergoing lecanemab therapy. Method Patients undergoing lecanemab therapy at Mayo Clinic, Rochester, MN were recruited to participate in this study. Patients were asked to provide an EDTA‐plasma sample before treatment initiation during the first infusion visit and thereafter at 3‐, 6‐, 12‐, and 18 months post‐treatment. p ‐tau217, p ‐tau181, GFAP, NfL, Aβ42, Aβ40, Aβ42/40, and p ‐tau217/Aβ42 measurements were obtained using Fujirebio Lumipulse assays. Biomarker median differences were assessed between all time points. Patients were grouped into three categories: a decreased biomarker (median decrease of at least 10%), an increased biomarker (median increase of at least 10%), and a stable biomarker (median change < +/−10%.) Biomarker data up to 6 months after treatment is presented. Result Of forty‐one patients enrolled since November 2023, twenty had time points up to 6 months. None of the biomarkers showed a statistically significant median change from baseline at 3 months ( p >0.05). At 6 months, only Aβ42/40 showed a statistically significant median change (decrease) between 0 and 6 months ( n = 20, p = 0.0058). Table 1 shows patients grouped by median biomarker changes from baseline to 6 months. GFAP, p ‐tau217, and Aβ42/40 exhibited the greatest number of patients with decreased biomarker concentrations (80%, 60%, and 60% of patients with median decreases of ‐25%, ‐26%, and ‐18% respectively), followed by p ‐tau181 (50% of patients; median decrease ‐22%), p ‐tau217/Aβ42 (45% of patients; median decrease ‐40%) and Aβ42 (45% of patients; median decrease ‐18%). None of the patients showed a decreased NfL or Aβ40 concentration. Conclusion Preliminarily analysis revealed that GFAP, p ‐tau217, and Aβ42/40 had the most frequent post‐lecanemab biomarker decreases. Additional sample collection is ongoing to assess the association of AD BBM changes with Amyloid PET over time.

Abstract Background The objective of this study was to determine the predictive value of amyloid‐PET versus plasma %p‐tau217 (defined as the ratio of phosphorylated to non‐phosphorylated Tau217 × 100), Aβ42/40, and the amyloid probability score (APS2; which combines of Aβ42/40 and %p‐tau217) in tau‐PET transitions (T‐ to T+). Method Participants included were from the Mayo Clinic Study of Aging (MCSA) and had plasma markers measured by mass spectrometry (IP‐MS; C2N), had an amyloid‐PET scan, and had a tau‐PET negative scan (SUVR<1.29, temporal meta‐ROI) at the baseline, along with one or more follow‐up tau‐PET scans. Cox proportional hazard models were used to evaluate the relationship between C2N plasma %P‐Tau217 and APS2 and incident tau‐PET positivity (SUVR>=1.29) adjusting for age, sex, and APOE ε4. An analysis was also performed using amyloid‐PET centiloid as the predictor. Both the plasma markers and amyloid‐PET centiloid were scaled so that a one‐unit change corresponds to the respective interquartile range (IQR) for comparability of hazard ratios (HR). The analyses were repeated in the BioFINDER‐2 cohort for validation. Result 255 MCSA participants (122 female [47.8%] were included with a median age of 71.9 (IQR: 65.8, 78.8) years old, of which 37 progressed to tau‐PET positivity. At baseline, 238 (93.7%) were cognitively unimpaired. Higher baseline %p‐tau217 (HR: 1.52 [95% CI: 1.28, 1.8]), amyloid‐PET centiloid (HR: 1.47 [95% CI: 1.20, 1.79]), and APS2 (HR: 1.62 [95% CI: 1.22, 2.16]) were associated with an increased risk of progressing to tau‐PET positive (Figure 1). Aβ42/40 (HR: 1.06 [95% 0.604–1.867] was not associated with incident tau positivity Among 605 participants who were tau negative at index date in BioFINDER‐2 (316 (52.2%) cognitively unimpaired), with a median age of 70.2 (IQR: 60.5‐76.4), 33 progressed to tau positivity with higher %p‐tau217 (HR: 1.8 [95% CI: 1.5, 2.17]), amyloid‐PET centiloid (HR: 2.3 [95% CI: 1.77, 2.97]), and lower Aβ 42/40 (HR: 0.42 [95% CI: 0.21, 0.85]) at index date all associated with an increased risk of progressing to tau‐PET positive. Conclusion In two independent cohorts , %p‐tau217 provides predictive information about those who will convert from tau negative to tau positive on PET scan with the associations being similar to amyloid‐PET.

Abstract Background Neuropathologic evaluation is essential for diagnosing and treating dementia, but definitive diagnoses is only available after post‐mortem brain autopsy. Positron emission tomography (PET) offers a potential in vivo proxy for predicting neuropathology. This study proposes a semi‐supervised learning (SSL) model using a single FDG‐PET image to predict underlying neuropathology. Method The SSL model leverages a self‐organized graph structure based on a patient similarity network (PSN) created from 1,495 FDG‐PET images across the aging and neurodegenerative spectrum. Each patient is represented by a node, with edges indicating image similarity derived from principal component analysis features and cosine similarity weights. The PSN structure connects 20 nearest neighbors. Neuropathologic labels were available for 204 autopsied patients. The Poisson Learning Method was employed to propagate labels from these annotated nodes to unlabeled nodes, guided by the PSN structure. FDG‐PET images were collected from clinical and research participants at the Mayo Clinic and processed using an MRI‐free pipeline. Neuropathologic labels were assigned based on widely accepted diagnostic criteria. Leave‐one‐out cross‐validation (LOOCV) was used to assess model performance. Results The confusion matrix demonstrated high accuracy in predicting Alzheimer's disease, frontotemporal lobar degeneration with tau inclusions, and Lewy body disease pathology. A Sankey diagram and label distribution analysis revealed strong correlations between clinical and predicted neuropathologic labels. Conclusion This study highlights the potential of a graph‐based SSL pipeline to predict neuropathological changes using FDG‐PET imaging data, despite limited pathology labels. The findings underscore the value of SSL in bridging the gap between abundant neuroimaging data and scarce neuropathologic labels, contributing to improved dementia diagnosis and understanding.

Abstract Background Alzheimer’s Disease (AD) progression is conceptualized as a cascade of sigmoidal (S‐shaped) curves, with biomarkers shifting sequentially from normal to abnormal states. Estimating these curves requires sophisticated modeling, with challenges including (1) selecting appropriate sigmoidal‐type functions, (2) achieving algorithmic convergence, and (3) producing clinically useful parameters. We compare commonly used sigmoidal‐functions and effects on novel estimates of early and late AD‐biomarker progression ages. Method Using 3,999 Amyloid PET (PiB SUVR) measurements from 1,367 Mayo Clinic Study of Aging participants, we compared model fits (AIC, BIC) between logistic and hyperbolic functions using Non‐Linear Mixed Effect (NLME) models with subject‐specific age‐shifts. We defined novel “initial” and “maximum” acceleration points (IAP and MAP) to compare clinically “earlier” and “later” AD‐progression ages between sigmoidal‐curves. The MAP uses the maximum second‐derivative point, reflecting the age of fastest acceleration in biomarker accumulation. The IAP is defined as the first point where the second derivative of the sigmoidal‐curve exceeds a clinical threshold (here, 5% velocity increase per year), indicating onset age of early accelerated biomarker accumulation. Estimates for C 2 N plasma p ‐tau217 were also attempted (1,306 measurements on 457 participants). Models adjusted for sex and APOE4‐positivity. Result In the larger PET sample, the hyperbola had lower AIC/BIC (better fit), but showed a decreasing early PiB‐SUVR trend (Table 1A, Figure 1). Ages of late MAP were comparable, as were sex and APOE4+ related PiB‐SUVR‐curve shifts. Age of early AD‐onset was estimated 1.5 years earlier for logistic (IAP=63.6) versus hyperbola (IAP=65.1) functions. The logistic function always converged, while the hyperbolic function did not converge for p ‐tau217 in the smaller C 2 N sample. Early‐onset and late‐progression ages were 7‐8 years later for p ‐tau217 versus PiB‐SUVR using logistic‐curves. Conclusion Late AD‐progression and covariate‐related shifts in progression were comparable across models, suggesting robustness to sigmoid choice. In contrast, estimates of early AD‐onset may be more dependent on functional form. While logistic‐sigmoids inherently increase monotonically, hyperbolas do not, here estimating a decline in initial amyloid trend. Future work may explore adding biologically informed constraints to flexible sigmoidal‐functions, and alternative Bayesian approaches, to optimize both model fit and estimation of early AD‐onset age.