All drug trials of the Alzheimer's disease (AD) have failed to slow the progression of dementia in phase III studies, and the most effective therapeutic strategy remains controversial due to the poorly understood disease mechanisms. For AD drug design, amyloid beta (Aβ) and its cascade have been the primary focus since decades ago, but mounting evidence indicates that the underpinning molecular pathways of AD are more complex than the classical reductionist models. Several genome-wide association studies (GWAS) have recently shed light on dark aspects of AD from a hypothesis-free perspective. Here, I use this novel insight to suggest that the amyloid cascade hypothesis may be a wrong model for AD therapeutic design. I review 23 novel genetic risk loci and show that, as a common theme, they code for receptor proteins and signal transducers of cell adhesion pathways, with clear implications in synaptic development, maintenance, and function. Contrary to the Aβ-based interpretation, but further reinforcing the unbiased genome-wide insight, the classical hallmark genes of AD including the amyloid precursor protein (APP), presenilins (PSEN), and APOE also take part in similar pathways of growth cone adhesion and contact-guidance during brain development. On this basis, I propose that a disrupted synaptic adhesion signaling nexus, rather than a protein aggregation process, may be the central point of convergence in AD mechanisms. By an exploratory bioinformatics analysis, I show that synaptic adhesion proteins are encoded by largest known human genes, and these extremely large genes may be vulnerable to DNA damage accumulation in aging due to their mutational fragility. As a prototypic example and an immediately testable hypothesis based on this argument, I suggest that mutational instability of the large Lrp1b tumor suppressor gene may be the primary etiological trigger for APOE-dab1 signaling disruption in late-onset AD. In conclusion, the large gene instability hypothesis suggests that evolutionary forces of brain complexity have led to emergence of large and fragile synaptic genes, and these unstable genes are the bottleneck etiology of aging disorders including senile dementias. A paradigm shift is warranted in AD prevention and therapeutic design.
The clinical utility of gene testing for Alzheimer’s disease