Interactions of the presynaptic proteins, neuronal pentraxin 2 (NPTX2) and neurexin 2a (NRXN2a), with their respective postsynaptic functional partners, GluA4-containing glutamate (AMPA4) receptor and neuroligin 1 (NLGN1), enhance excitatory synaptic activity in some areas of the hippocampus and cerebral cortex. As early damage of such excitatory circuits in the brain tissues of participants with Alzheimer's disease (AD) correlates with cognitive losses, plasma neuron-derived exosome (NDE) levels of these 2 pairs of specialized synaptic proteins were quantified to assess their biomarker characteristics. The NDE contents of all 4 proteins were decreased significantly in AD dementia (n = 46), and diminished levels of AMPA4 and NLGN1 correlated with the extent of cognitive loss. In a preclinical period, 6-11 yr before the onset of dementia, the NDE levels of all but NPTX2 were significantly lower than those of matched controls, and levels of all proteins declined significantly with the development of dementia. Reductions in NDE levels of these specialized excitatory synaptic proteins may therefore be indicative of the extent of cognitive loss and may reflect progression of the severity of AD.-Goetzl, E. J., Abner, E. L., Jicha, G. A., Kapogiannis, D., Schwartz, J. B. Declining levels of functionally specialized synaptic proteins in plasma neuronal exosomes with progression of Alzheimer's disease. FASEB J. 32, 888-893 (2018). www.fasebj.orgDiminished synaptic function and loss of synapses are characteristic early elements of the neuropathology of Alzheimer's disease (AD), usually attributed to the neuronal deposition of neurotoxic amyloid-b (Ab) peptide oligomers (1, 2). The distribution and extent of brain synaptic pathology in postmortem brain tissues of patients with AD correlate generally with the severity of premortem cognitive loss (3, 4). Our initial analyses of plasma neuron-derived exosome (NDE) content of several synaptic proteins in AD demonstrated lower levels-similar to decreases in postmortem AD brain tissues-compared with those of matched controls. In cross-sectional studies, the plasma NDE levels of the presynaptic proteins, synaptotagmin and synaptophysin, and of the postsynaptic proteins, synaptopodin and neurogranin, in patients with AD were significantly lower than those for controls, whereas plasma NDE levels of the synaptic membrane protein, GAP43, were only marginally lower in patients with AD than in controls (5). The same synaptic proteins in NDEs from the plasma of participants who were initially cognitively normal but who subsequently developed definite AD dementia were at significantly lower preclinical levels than in plasma NDEs of matched controls (5). There was also a progressive decline of plasma NDE levels of synaptotagmin, synaptopodin, and GAP43, but not of synaptophysin or neurogranin, in these participants 2-10 yr later at the time of diagnosis of AD dementia.Synaptic proteins that were investigated in our first study are widely distributed in CNS synapses and share fun...