The cholinergic hypothesis was initially presented over 20 years ago and suggests that a dysfunction of acetylcholine containing neurons in the brain contributes substantially to the cognitive decline observed in those with advanced age and Alzheimer's disease (AD). This premise has since served as the basis for the majority of treatment strategies and drug development approaches for AD to date. Recent studies of the brains of patients who had mild cognitive impairment or early stage AD in which choline acetyltransferase and/or acetylcholinesterase activity was unaffected (or even up-regulated) have, however, led some to challenge the validity of the hypothesis as well as the rationale for using cholinomimetics to treat the disorder, particularly in the earlier stages. These challenges, primarily based on assays of post mortem enzyme activity, should be taken in perspective and evaluated within the wide range of cholinergic abnormalities known to exist in both aging and AD. The results of both post mortem and antemortem studies in aged humans and AD patients, as well as animal experiments suggest that a host of cholinergic abnormalities including alterations in choline transport, acetylcholine release, nicotinic and muscarinic receptor expression, neurotrophin support, and perhaps axonal transport may all contribute to cognitive abnormalities in aging and AD. Cholinergic abnormalities may also contribute to noncognitive behavioral abnormalities as well as the deposition of toxic neuritic plaques in AD. Therefore, cholinergic-based strategies will likely remain valid as one approach to rational drug development for the treatment of AD other forms of dementia.
The Cholinergic HypothesisA variety of studies in humans indicate that basal forebrain and rostral forebrain cholinergic pathways including converging projections to the thalamus serve important functional roles in conscious awareness, attention, working memory, and a number of additional mnemonic processes (Perry et al., 1999).For more than 20 years, studies of the brains of those with advanced age and Alzheimer's disease (AD) have consistently found damage or abnormalities in these pathways (particularly basal forebrain projections) that appeared to correlate well with the level of cognitive decline. As a result, the so-called "cholinergic hypothesis" was developed, which essentially states that a loss of cholinergic function in the central nervous system contributes significantly to the cognitive decline associated with advanced age and AD (reviewed, Bartus, 2000). Extensive literature from animal experiments supports the human data described above. In fact, the importance of cholinergic function in the brain to learning and memory was first recognized more than 30 years ago after cholinergic antagonists (specifically antimuscarinic agents) were found to impair memory in rats (Deutsch, 1971). Considerable additional evidence now supports this early work, and antimuscarinic agents such as scopolamine and atropine have been shown to impair memory