A THERAPEUTIC SYSTEM COMPRISING PHARMACEUTICALS IN COMBINATION WITH METABOLIC ENHANCEMENT FOR

NEURODEGENERATION

CROSS-REFERENCE TO RELATED APPLICATIONS

[0001] This application claims benefit of and priority to USSN 62/187,689, filed on

July 1, 2015, which is incorporated herein by reference in its entirety for all purposes.

STATEMENT OF GOVERNMENTAL SUPPORT

[0002] This invention was made with government support under Grant Nos.

AG034427 awarded by the National Institute of Aging. The Government has certain rights in this invention.

BACKGROUND

[0003] Cognitive decline is a major concern of the aging population, and

Alzheimer's disease is the major cause of age-related cognitive decline, with approximately 5.4 million American patients and 30 million affected globally (Prince et al. (2014) World Alzheimer Report 2014 United Kingdom: Alzheimer's Disease International). In the absence of effective prevention and treatment, the prospects for the future are of great concern, with 13 million Americans and 160 million globally projected for 2050, leading to potential bankruptcy of the Medicare system. Unlike several other chronic illnesses, Alzheimer's disease (AD) prevalence is on the rise, which makes the need to develop effective prevention and treatment increasingly pressing. Recent estimates suggest that AD has become the third leading cause of death in the United States (James et al. (2014) Neurology. 82: 1045-1050), behind cardiovascular disease and cancer. Furthermore, it has been pointed out recently that women are at the epicenter of the Alzheimer's epidemic, with 65% of patients and 60% of caregivers being women (Shriver (2010) A Woman's Nation Takes on Alzheimer's. New York, USA: Alzheimer's Association). Indeed, a woman's chance of developing AD is now greater than her chance of developing breast cancer (Alzheimer's Association (2014) Alzheimer's Disease Facts and Figures. Special Report on Women and Alzheimer's Disease. USA: pp. 1-80).

[0004] Neurodegenerative disease therapeutics has been, arguably, the field of greatest failure of biomedical therapeutics development. Patients with acute illnesses such as infectious diseases, or with other chronic illnesses, such as cardiovascular disease, osteoporosis, human immunodeficiency virus infection, and even cancer, have access to more effective therapeutic options than do patients with AD or other neurodegenerative diseases such as Lewy body dementia, frontotemporal lobar degeneration, and amyotrophic lateral sclerosis. In the case of Alzheimer's disease, there is not a single therapeutic that exerts anything beyond a marginal, unsustained, symptomatic effect, with little or no effect on disease progression. Furthermore, in the past decade alone, hundreds of clinical trials have been conducted for AD, at an aggregate cost of billions of dollars, without success. This has led some to question whether the approach taken to drug development for AD is an optimal one. [0005] Therapeutic success for other chronic illnesses such as cardiovascular disease, cancer, and HIV, has been improved through the use of combination therapies (Bredesen and John 92013) EMBOMolMed. 5: 795-798). In the case of AD and its predecessors, mild cognitive impairment (MCI) and subjective cognitive impairment (SCI), comprehensive combination therapies have not been explored. SUMMARY

[0006] Various embodiments contemplated herein may include, but need not be limited to, one or more of the following:

[0007] Embodiment 1 : A method of increasing the magnitude of efficacy and/or the duration of efficacy and patient responsiveness to a drug for the treatment of MCI, dementia, and/or Alzheimer's disease, said method comprising: administering an effective amount of said drug in combination with a therapeutic system comprising a comprehensive Metabolic Enhancement for Neurodegeneration (MEND) program or a subset thereof.

[0008] Embodiment 2: The method of embodiment 1, wherein said method is for the treatment of Alzheimer's disease (AD). [0009] Embodiment 3 : The method of embodiment 1, wherein said method is for the treatment of amnestic mild cognitive impairment (aMCI).

[0010] Embodiment 4: The method of embodiment l,wherein said method is for the treatment of subject cognitive impairment (SCI).

[0011] Embodiment 5: The method according to any one of embodiments 1-4, wherein said method increases the degree of efficacy of said drug as compared to the use of said drug without said therapeutic system. [0012] Embodiment 6: The method of embodiment 5, wherein said degree of efficacy is determined as a reduction in symptoms.

[0013] Embodiment 7: The method of embodiment 5, wherein said degree of efficacy is determined by neuropsychological testing. [0014] Embodiment 8: The method according to any one of embodiments 1-7, wherein said method increases the duration of efficacy of said drug as compared to the use of said drug without said therapeutic system

[0015] Embodiment 9: The method according to any one of embodiments 1-8, wherein said increase in efficacy and/or reduction in symptoms comprises a reduction in the CSF of levels of one or more components selected from the group consisting of Αβ42, sAPPp, total-Tau (tTau), phospho-Tau (pTau), APPneo, soluble Αβ40, pTau/Ap42 ratio and tTau/Ap42 ratio, and/or an increase in the CSF of levels of one or more components selected from the group consisting of Αβ42/Αβ40 ratio, Αβ42/Αβ38 ratio, sAPPa, βΑΡΡα/βΑΡΡβ ratio, 8ΑΡΡα/Αβ40 ratio, and 8ΑΡΡα/Αβ42 ratio. [0016] Embodiment 10: The method according to any one of embodiments 1-9, wherein said increase in efficacy and/or reduction in symptoms comprises a reduction of the plaque load in the brain of the subject.

[0017] Embodiment 11 : The method according to any one of embodiments 1-10, wherein said increase in efficacy and/or reduction in symptoms comprises a reduction in the rate of plaque formation in the brain of the subject.

[0018] Embodiment 12: The method according to any one of embodiments 1-11, wherein said increase in efficacy and/or reduction in symptoms comprises an improvement in the cognitive abilities of the subject.

[0019] Embodiment 13 : The method according to any one of embodiments 1-12, wherein said increase in efficacy and/or reduction in symptoms comprises improvement in, a stabilization of, or a reduction in the rate of decline of the clinical dementia rating (CDR) of the subject.

[0020] Embodiment 14: The method according to any one of embodiments 1-13, wherein the subject is a human and said increase in efficacy and/or reduction in symptoms comprises a perceived improvement in quality of life by the human. [0021] Embodiment 15: The method according to any one of embodiments 1-14, wherein said therapeutic system comprises: nutritional modulation; and dietary

supplementation.

[0022] Embodiment 16: The method of embodiment 15, wherein said therapeutic system comprises sleep and/or lifestyle modification.

[0023] Embodiment 17: The method according to any one of embodiments 1-16, wherein said therapeutic system comprises dietary supplementation comprising: fish oil or omega 3 (DHA) supplementation; coenzyme Q10 supplementation; curcumin/day (turmeric) supplementation; folic acid supplementation; citicholine supplementation; and resveratrol supplementation.

[0024] Embodiment 18: The method according to any one of embodiments 1-17, wherein said therapeutic system comprises vitamin D3 supplementation.

[0025] Embodiment 19: The method of embodiment 18, wherein said vitamin D supplementation is at about 200 IU/day. [0026] Embodiment 20: The method according to any one of embodiments 1-19, wherein said therapeutic system comprises vitamin B supplementation.

[0027] Embodiment 21 : The method of embodiment 20, wherein said vitamin B supplementation comprises supplementation with methylcobalamin (vitamin B 12).

[0028] Embodiment 22: The method according to any one of embodiments 20-21, wherein said vitamin B supplementation comprises supplementation with one or more vitamins selected from the group consisting of vitamin Bl, vitamin B2, vitamin B3, vitamin B4, vitamin B5, and vitamin B6.

[0029] Embodiment 23 : The method according to any one of embodiments 1-22, wherein said therapeutic system comprises dietary supplementation comprising fish oil or omega 3 (DHA) supplementation at about 250 mg/day.

[0030] Embodiment 24: The method according to any one of embodiments 1-23, wherein said therapeutic system comprises H. erinaceus and/or ALCAR.

[0031] Embodiment 25: The method of embodiment 24, wherein said H. erinaceus and/or ALCAR is at about 250 mg/day. [0032] Embodiment 26: The method according to any one of embodiments 1-25, wherein said therapeutic system comprise one or more of the following: anti-oxidants tocopherols/tocotrienols, Se, N-acetyl cysteine (NAC), ascorbate, and a-lipoic acid.

[0033] Embodiment 27: The method according to any one of embodiments 1-26, wherein said therapeutic system comprises dietary supplementation comprising coenzyme Q10 supplementation at about 200 mg/day.

[0034] Embodiment 28: The method according to any one of embodiments 1-27, wherein said therapeutic system comprises dietary supplementation comprising turmeric (curcumin) supplementation at about 400 mg/day. [0035] Embodiment 29: The method according to any one of embodiments 1-28, wherein said therapeutic system comprises dietary supplementation comprising folic acid supplementation at about 0.8 mg methyltetrahydrofolate daily.

[0036] Embodiment 30: The method according to any one of embodiments 1-29, wherein said therapeutic system comprises dietary supplementation comprising citicholine supplementation at about 500 mg po.

[0037] Embodiment 31 : The method according to any one of embodiments 1-30, wherein said therapeutic system comprises dietary supplementation comprising alpha glycerophosphorylcholine (alpha-GPC) supplementation at about 250 mg po.

[0038] Embodiment 32: The method according to any one of embodiments 1-31, wherein said therapeutic system comprises dietary supplementation comprising Bacopa monniera, and/or pantothenic acid, and/or magnesium threonate and/or magnesium glycinate.

[0039] Embodiment 33 : The method of embodiment 32, wherein said Bacopa monniera is provided at about 250mg daily. [0040] Embodiment 34: The method according to any one of embodiments 1-33, wherein said therapeutic system comprises dietary supplementation comprising

ashwagandha and/or curcumin.

[0041] Embodiment 35: The method of embodiment 34, wherein said ashwagandha is provided at about 500mg daily. [0042] Embodiment 36: The method of embodiment 34, wherein said curcumin is provided at about 400mg daily. [0043] Embodiment 37: The method according to any one of embodiments 1-36, wherein said therapeutic system comprises dietary supplementation comprising

administration of melatonin.

[0044] Embodiment 38: The method of embodiment 37, wherein said melatonin is administered at about 0.5 mg qhs.

[0045] Embodiment 39: The method according to any one of embodiments 1-38, wherein said therapeutic system comprises dietary supplementation comprising

administration of tryptophan.

[0046] Embodiment 40: The method of embodiment 39, wherein said tryptophan is administered at about 500 mg 3 times per week.

[0047] Embodiment 41 : The method according to any one of embodiments 1-40, wherein the supplementation includes dietary supplementation with caffeine.

[0048] Embodiment 42: The method according to any one of embodiments 1-41, wherein said therapeutic system comprises nutritional modification comprising substantial elimination of simple carbohydrates.

[0049] Embodiment 43 : The method according to any one of embodiments 1-42, wherein said therapeutic system comprises nutritional modification comprising substantial elimination of gluten.

[0050] Embodiment 44: The method according to any one of embodiments 1-43, wherein said therapeutic system comprises nutritional modification comprising substantial reduction in consumption of processed foods.

[0051] Embodiment 45: The method according to any one of embodiments 1-44, wherein said therapeutic system comprises nutritional modification comprising increased vegetable and/or fruit consumption. [0052] Embodiment 46: The method of embodiment 45, wherein said increased vegetable and/or fruit consumption is at least three servings per day.

[0053] Embodiment 47: The method according to any one of embodiments 1-46, wherein said therapeutic system comprises nutritional modification comprising increased fruit consumption. [0054] Embodiment 48: The method of embodiment 47, wherein said increased fruit consumption is at least two servings per day. [0055] Embodiment 49: The method according to any one of embodiments 1-48, wherein said therapeutic system comprises nutritional modification comprising increased fish consumption.

[0056] Embodiment 50: The method of embodiment 49, wherein said increased fish consumption is consumption two to three times a week of non-farm raised fish.

[0057] Embodiment 51 : The method according to any one of embodiments 1-50, wherein said therapeutic system comprises nutritional modification comprising increased ketogenic intake.

[0058] Embodiment 52: The method of embodiment 51, wherein said increased ketogenic intake comprises intake of coconut oil and/or axona.

[0059] Embodiment 53 : The method according to any one of embodiments 1-52, wherein said therapeutic system comprises consumption of 1-2 cups of coffee or tea per day.

[0060] Embodiment 54: The method according to any one of embodiments 1-53, wherein said therapeutic system comprises consumption of probiotic capsules or food.

[0061] Embodiment 55: The method according to any one of embodiments 1-54, wherein said therapeutic system comprises sleep and/or lifestyle modification comprising fasting 12 hours per day and 3 hours before sleep.

[0062] Embodiment 56: The method according to any one of embodiments 1-55, wherein said therapeutic system comprises sleep and/or lifestyle modification comprising increasing sleep duration to at least about 7-8 hours, but not more than 9 hours.

[0063] Embodiment 57: The method according to any one of embodiments 1-56, wherein said therapeutic system comprises sleep and/or lifestyle modification comprising treating sleep apnea. [0064] Embodiment 58: The method according to any one of embodiments 1-57, wherein said therapeutic system comprises sleep and/or lifestyle modification comprising brain stimulation.

[0065] Embodiment 59: The method of embodiment 58, wherein said brain stimulation comprises one or more activities selected from the group consisting of performance of one or more daily puzzles, use of brain training software, and reading. [0066] Embodiment 60: The method according to any one of embodiments 1-59, wherein said therapeutic system comprises sleep and/or lifestyle modification comprising strict oral hygiene and care.

[0067] Embodiment 61 : The method of embodiment 60, wherein said oral hygiene in includes brushing flossing, and treatment of all dental issues.

[0068] Embodiment 62: The method according to any one of embodiments 1-61, wherein said therapeutic system comprises sleep and/or lifestyle modification comprising exercise for at least 30 minutes 4-6 days per week.

[0069] Embodiment 63 : The method according to any one of embodiments 1-62, wherein said therapeutic system comprises sleep and/or lifestyle modification comprising stress reduction.

[0070] Embodiment 64: The method of embodiment 63, wherein said stress reduction comprises one or more activities selected from the group consisting of yoga, meditation, and music. [0071] Embodiment 65: The method according to any one of embodiments 1-64, wherein said therapeutic system comprises treatment of hearing loss.

[0072] Embodiment 66: The method according to any one of embodiments 1-65, wherein said therapeutic system comprises treatment of loss of vision.

[0073] Embodiment 67: The method according to any one of embodiments 1-66, wherein said therapeutic system comprises a review of all medications and dosages to identify interactions.

[0074] Embodiment 68: The method according to any one of embodiments 1-67, wherein said therapeutic system comprises maintenance of bone density.

[0075] Embodiment 69: The method of embodiment 68, wherein said maintenance of bone density comprises D3 supplementation with calcium and/or or osteoclast mediated bone resorption inhibitor.

[0076] Embodiment 70: The method according to any one of embodiments 1-69, wherein said therapeutic system comprises identification and treatment of insulin resistance or diabetes. [0077] Embodiment 71 : The method according to any one of embodiments 1-70, wherein said therapeutic system comprises identification and treatment of any chronic infection.

[0078] Embodiment 72: The method according to any one of embodiments 1-71, wherein said therapeutic system comprises identification and treatment of heavy metal toxicity.

[0079] Embodiment 73 : The method according to any one of embodiments 1-72, wherein said therapeutic system comprises identification and treatment of cardiovascular issues. [0080] Embodiment 74: The method of embodiment 73, wherein said

cardiovascular issues comprise hypertension and/or high cholesterol.

[0081] Embodiment 75: The method according to any one of embodiment 74, wherein said method comprises administration of an agent to lower cholesterol.

[0082] Embodiment 76: The method of embodiment 75, wherein said agent to lower cholesterol is selected from the group consisting of statins (e.g., atorvastatin

(LIPITOR®), fluvastatin (LESCOL®), lovastatin (MEVACOR®, ALTOPREV™), pravastatin (PRAVACHOL®), rosuvastatin calcium (CRESTOR®), simvastatin

(ZOCOR®) and combinations thereof (e.g. , ADVICOR® (lovastatin + niacin), CADUET® (atorvastatin + amlodipine), VYTORIN™ (simvastatin + ezetimibe), etc.), selective cholesterol absorption inhibitors (e.g., ezetimibe (ZETIA®)), resins (e.g., bile acid sequestrants such as cholestyramine (QUESTRAN®, QUESTRAN® LIGHT,

PREVALITE®, LOCHOLEST®, LOCHOLEST® light), colestipol (Colestid®), colesevelam HC1 (WELCHOL®)), fibrates (e.g., gemfibrozil (LOPID®), fenofibrate (ANTARA®, LOFIBRA®, TRICOR®, and TRIGLIDE™), clofibrate (ATROMID-S)), niacin (nicotinic acid), o mega-3 fatty acid ethyl esters (e.g., LOVAZA®, VASCEPA™), and marine-derived omega-3 polyunsaturated fatty acids (PUFA).

[0083] Embodiment 77: The method according to any one of embodiments 74-76, wherein said method comprises administration of an agent to treat hypertension.

[0084] Embodiment 78: The method of embodiment 77, wherein said agent to treat hypertension is selected from the group consisting of thiazide diuretics (e.g.,

hydrochlorothiazide (MICROZIDE®, CHLORTHALIDONE®), etc.), beta blockers (e.g. acebutolol (SECTRAL®), atenolol (TENORMIN®), etc.), angiotensin-converting enzyme (ACE) inhibitors (e.g., lisinopril (ZESTRIL®), benazepril (LOTENSIN®), captopril (CAPOTEN®), etc.), angiotensin II receptor blockers (ARBs) (e.g., candesartan

(AT AC AND®), losartan (COZAAR®), etc.), calcium channel blockers (e.g., amlodipine (NORVASC®), diltiazem (CARDIZEM®, TIAZAC®), etc.), renin inhibitors (e.g., Aliskiren (TEKTURNA®), etc.), alpha blockers (e.g., doxazosin (CARDURA®), prazosin (MINIPRESS®), etc.), alpha-beta blockers (e.g., carvedilol (COREG®), labetalol

(TRANDATE®), etc.), central-acting agents (e.g., clonidine (CATAPRES®, KAPVAY®), etc.), guanfacine (INTUNIV®, TENEX®), methyldopa, etc.), vasodilators, and aldosterone antagonists (e.g., spironolactone (ALDACTONE®), eplerenone (INSPRA®), etc.). [0085] Embodiment 79: The method according to any one of embodiments 1-78, wherein said drug for the treatment of MCI, dementia, and/or Alzheimer's disease is an FDA approved drug for the treatment of Alzheimer's disease.

[0086] Embodiment 80: The method of embodiment 79, wherein said drug is donepezil (e.g. ARICEPT®). [0087] Embodiment 81 : The method of embodiment 79, wherein said drug is galantamine (e.g., RAZADYNE®).

[0088] Embodiment 82: The method of embodiment 79, wherein said drug is memantine (e.g., NAMENDA® and/or NAMENDA XR).

[0089] Embodiment 83 : The method of embodiment 79, wherein said drug is rivastigmine (e.g. , EXELON® and/or EXELON® patch).

[0090] Embodiment 84: The method of embodiment 79, wherein said drug is tacrine (e.g., COGNEX®).

[0091] Embodiment 85: The method of embodiment 79, wherein said drug is a combination of donepezil and memantine (e.g., NAMZARIC®). [0092] Embodiment 86: The method according to any one of embodiments 1-74, wherein said drug is a drug in development for the treatment of Alzheimer's disease.

[0093] Embodiment 87: The method of embodiment 86, wherein said drug is tropisetron and/or analogues thereof.

[0094] Embodiment 88: The method of embodiment 86, wherein said drug is a tropinol-ester and/or related esters and/or analogues thereof. [0095] Embodiment 89: The method of embodiment 86, wherein said drug is a

TrkA kinase inhibitor (e.g., ADDN-1351) and/or analogue thereof.

[0096] Embodiment 90: The method of embodiment 86, wherein said drug is an

APP-specific BACE inhibitor (ASBI). [0097] Embodiment 91 : The method of embodiment 86, wherein said drug is a hydantoin.

[0098] Embodiment 92: The method of embodiment 86, wherein said drug is a

CRF1 inhibitor and can inhibit Cortisol induced p-Tau production.

[0099] Embodiment 93 : The method of embodiment 92, wherein said drug comprises N-(4-Methoxy-2-methylphenyl)- 1 -[ 1 -(methoxymethyl)propyl]-6-methyl- 1H- l,2,3-triazolo[4,5-c]pyridin-4-amine.

[0100] Embodiment 94: The method of embodiment 86, wherein said drug is a galangin, a galangin prodrug, rutin, a rutin prodrug, and other flavonoids and flavonoid prodrugs. [0101] Embodiment 95: The method of embodiment 86, wherein said drug is an inhibitor of Αβ aggregation, or increases Αβ clearance.

[0102] Embodiment 96: The method of embodiment 86, wherein said drug is an inhibitor of Αβ production through inhibition of BACE or γ-secretase.

[0103] Embodiment 97: The method of embodiment 86, wherein said drug is an inhibitor of C31 production.

[0104] Embodiment 98: The method of embodiment 86, wherein said drug increases sAPPalpha levels.

[0105] Embodiment 99: The method of embodiment 86, wherein said drug inhibits

Tau phosphorylation and aggregation. [0106] Embodiment 100: A method of evaluating a drug for the treatment of MCI, dementia, and/or Alzheimer's disease, said method comprising: providing a population of subjects having or at risk for MCI, dementia, and/or Alzheimer's disease; administering to said subjects a therapeutic system comprising a comprehensive Metabolic Enhancement for Neurodegeneration (MEND) program or a subset thereof; administering to said subjects said drug that is to be evaluated; and evaluating over time the response of said subjects to said drug. [0107] Embodiment 101 : The method of embodiment 100, wherein said drug is a drug for the treatment of Alzheimer's disease (AD) and/or amnestic mild cognitive impairment (aMCI), and/or subject cognitive impairment (SCI).

[0108] Embodiment 102: The method according to any one of embodiments 100- 101, wherein said evaluating comprises: determining if said drug prevents or delays the transition from a cognitively asymptomatic pre- Alzheimer's condition to a pre- Alzheimer's cognitive dysfunction; and/or determining if said drug prevents or delays the onset of a pre- Alzheimer's cognitive dysfunction; and/or determining if said drug ameliorates one or more symptoms of a pre- Alzheimer's cognitive dysfunction; and/or determining if said drug prevents or delays the progression of a pre- Alzheimer's cognitive dysfunction to

Alzheimer's disease; and/or identifying elevated markers of neuronal injury selected from the group consisting of tau, and FDG uptake; and/or detecting a reduction in the CSF of levels of one or more components selected from the group consisting of Αβ42, sAPPp, total - Tau (tTau), phospho-Tau (pTau), APPneo, soluble Αβ40, pTau/Ap42 ratio and tTau/Ap42 ratio, and/or an increase in the CSF of levels of one or more components selected from the group consisting of Αβ42/Αβ40 ratio, Αβ42/Αβ38 ratio, sAPPa, βΑΡΡα/βΑΡΡβ ratio, 8ΑΡΡα/Αβ40 ratio, and 8ΑΡΡα/Αβ42 ratio.

[0109] Embodiment 103 : The method according to any one of embodiments 100-

102, wherein said therapeutic system comprises: nutritional modulation; and dietary supplementation.

[0110] Embodiment 104: The method according to any one of embodiments 100-

103, wherein said therapeutic system comprises sleep and lifestyle modification.

[0111] Embodiment 105: The method according to any one of embodiments 100-

104, wherein said therapeutic system comprises dietary supplementation comprising: fish oil or omega 3 (DHA) supplementation; coenzyme Q10 supplementation; curcumin/day

(turmeric) supplementation; folic acid supplementation; citicholine supplementation; and resveratrol supplementation.

[0112] Embodiment 106: The method according to any one of embodiments 100-

105, wherein said therapeutic system comprises vitamin D3 supplementation. [0113] Embodiment 107: The method of embodiment 106, wherein said vitamin D supplementation is at about 200 IU/day. [0114] Embodiment 108: The method according to any one of embodiments 100-

107, wherein said therapeutic system comprises vitamin B supplementation.

[0115] Embodiment 109: The method of embodiment 108, wherein said vitamin B supplementation comprises supplementation with methylcobalamin (vitamin B 12). [0116] Embodiment 110: The method according to any one of embodiments 108-

109, wherein said vitamin B supplementation comprises supplementation with one or more vitamins selected from the group consisting of vitamin Bl, vitamin B2, vitamin B3, vitamin B4, vitamin B5, and vitamin B6.

[0117] Embodiment 111 : The method according to any one of embodiments 100- 110, wherein said therapeutic system comprises vitamin D3 supplementation.

[0118] Embodiment 112: The method of embodiment 111, wherein said vitamin D supplementation is at about 200 IU/day.

[0119] Embodiment 113 : The method according to any one of embodiments 100-

112, wherein said therapeutic system comprises dietary supplementation comprising fish oil or omega 3 (DHA) supplementation at about 250 mg/day.

[0120] Embodiment 114: The method according to any one of embodiments 100-

113, wherein said therapeutic system comprises H. erinaceus and/or ALCAR.

[0121] Embodiment 115: The method of embodiment 114, wherein said H.

erinaceus and/or ALCAR is at about 250 mg/day. [0122] Embodiment 116: The method according to any one of embodiments 100-

115, wherein said therapeutic system comprise one or more of the following: anti-oxidants tocopherols/tocotrienols, Se, N-acetyl cysteine (NAC), ascorbate, and a-lipoic acid.

[0123] Embodiment 117: The method according to any one of embodiments 100-

116, wherein said therapeutic system comprises dietary supplementation comprising coenzyme Q10 supplementation at about 200 mg/day.

[0124] Embodiment 118: The method according to any one of embodiments 100-

117, wherein said therapeutic system comprises dietary supplementation comprising turmeric supplementation at about 400 mg/day.

[0125] Embodiment 119: The method according to any one of embodiments 100- 118, wherein said therapeutic system comprises dietary supplementation comprising folic acid supplementation at about 0.8 mg methyltetrahydrofolate daily. [0126] Embodiment 120: The method according to any one of embodiments 100-

119, wherein said therapeutic system comprises dietary supplementation comprising citicholine supplementation at about 500 mg po.

[0127] Embodiment 121 : The method according to any one of embodiments 100- 120, wherein said therapeutic system comprises dietary supplementation comprising alpha glycerophosphorylcholine (alpha-GPC) supplementation at about 250 mg po.

[0128] Embodiment 122: The method according to any one of embodiments 100-

121, wherein said therapeutic system comprises dietary supplementation comprising Bacopa monniera, and/or pantothenic acid, and/or magnesium threonate and/or magnesium glycinate.

[0129] Embodiment 123 : The method of embodiment 122, wherein said Bacopa monniera is provided at about 250 mg daily.

[0130] Embodiment 124: The method according to any one of embodiments 100-

123, wherein said therapeutic system comprises dietary supplementation comprising ashwagandha and/or curcumin.

[0131] Embodiment 125: The method of embodiment 124, wherein said

ashwagandha is provided at about 500mg daily.

[0132] Embodiment 126: The method of embodiment 124, wherein said curcumin is provided at about 400mg daily. [0133] Embodiment 127: The method according to any one of embodiments 100-

126, wherein said therapeutic system comprises dietary supplementation comprising administration of melatonin.

[0134] Embodiment 128: The method of embodiment 127, wherein said melatonin is administered at about 0.5 mg qhs. [0135] Embodiment 129: The method according to any one of embodiments 100-

128, wherein said therapeutic system comprises dietary supplementation comprising administration of tryptophan.

[0136] Embodiment 130: The method of embodiment 129, wherein said tryptophan is administered at about 500 mg 3 times per week. [0137] Embodiment 131 : The method according to any one of embodiments 100-

130, wherein the supplementation includes dietary supplementation with caffeine. [0138] Embodiment 132: The method according to any one of embodiments 100-

131, wherein said therapeutic system comprises nutritional modification comprising substantial elimination of simple carbohydrates.

[0139] Embodiment 133 : The method according to any one of embodiments 100- 132, wherein said therapeutic system comprises nutritional modification comprising substantial elimination of gluten.

[0140] Embodiment 134: The method according to any one of embodiments 100-

133, wherein said therapeutic system comprises nutritional modification comprising substantial reduction in consumption of processed foods. [0141] Embodiment 135: The method according to any one of embodiments 100-

134, wherein said therapeutic system comprises nutritional modification comprising increased vegetable and/or fruit consumption.

[0142] Embodiment 136: The method of embodiment 135, wherein said increased vegetable and/or fruit consumption is at least three servings per day. [0143] Embodiment 137: The method according to any one of embodiments 100-

136, wherein said therapeutic system comprises nutritional modification comprising increased fruit consumption.

[0144] Embodiment 138: The method of embodiment 137, wherein said increased fruit consumption is at least two servings per day. [0145] Embodiment 139: The method according to any one of embodiments 100-

138, wherein said therapeutic system comprises nutritional modification comprising increased fish consumption.

[0146] Embodiment 140: The method of embodiment 139, wherein said increased fish consumption is consumption two to three times a week of non-farm raised fish. [0147] Embodiment 141 : The method according to any one of embodiments 100-

140, wherein said therapeutic system comprises nutritional modification comprising increased ketogenic intake.

[0148] Embodiment 142: The method of embodiment 141, wherein said increased ketogenic intake comprises intake of coconut oil and/or axona. [0149] Embodiment 143 : The method according to any one of embodiments 100-

142, wherein said therapeutic system comprises consumption of 1-2 cups of coffee or tea per day.

[0150] Embodiment 144: The method according to any one of embodiments 100- 143, wherein said therapeutic system comprises consumption of probiotic capsules or food.

[0151] Embodiment 145: The method according to any one of embodiments 100-

144, wherein said therapeutic system comprises sleep and/or lifestyle modification comprising fasting 12 hours per day and 3 hours before sleep.

[0152] Embodiment 146: The method according to any one of embodiments 100- 145, wherein said therapeutic system comprises sleep and/or lifestyle modification comprising increasing sleep duration to at least about 7-8 hours, but not more than 9 hours.

[0153] Embodiment 147: The method according to any one of embodiments 100-

146, wherein said therapeutic system comprises sleep and/or lifestyle modification comprising treating sleep apnea. [0154] Embodiment 148: The method according to any one of embodiments 100-

147, wherein said therapeutic system comprises sleep and/or lifestyle modification comprising brain stimulation.

[0155] Embodiment 149: The method of embodiment 148, wherein said brain stimulation comprises one or more activities selected from the group consisting of performance of one or more daily puzzles, use of brain training software, and reading.

[0156] Embodiment 150: The method according to any one of embodiments 100-

149, wherein said therapeutic system comprises sleep and/or lifestyle modification comprising strict oral hygiene and care.

[0157] Embodiment 151 : The method of embodiment 150, wherein said oral hygiene in includes brushing flossing, and treatment of all dental issues.

[0158] Embodiment 152: The method according to any one of embodiments 100-

151, wherein said therapeutic system comprises sleep and/or lifestyle modification comprising exercise for at least 30 minutes 4-6 days per week.

[0159] Embodiment 153 : The method according to any one of embodiments 100- 152, wherein said therapeutic system comprises sleep and/or lifestyle modification comprising stress reduction. [0160] Embodiment 154: The method of embodiment 153, wherein said stress reduction comprises one or more activities selected from the group consisting of yoga, meditation, and music.

[0161] Embodiment 155: The method according to any one of embodiments 100- 154, wherein said therapeutic system comprises treatment of hearing loss.

[0162] Embodiment 156: The method according to any one of embodiments 100-

155, wherein said therapeutic system comprises treatment of loss of vision.

[0163] Embodiment 157: The method according to any one of embodiments 100-

156, wherein said therapeutic system comprises a review of all medications and dosages to identify interactions.

[0164] Embodiment 158: The method according to any one of embodiments 100-

157, wherein said therapeutic system comprises maintenance of bone density.

[0165] Embodiment 159: The method of embodiment 158, wherein said maintenance of bone density comprises D3 supplementation with calcium and/or or osteoclast mediated bone resorption inhibitor.

[0166] Embodiment 160: The method according to any one of embodiments 100-

159, wherein said therapeutic system comprises identification and treatment of insulin resistance or diabetes.

[0167] Embodiment 161 : The method according to any one of embodiments 100- 160, wherein said therapeutic system comprises identification and treatment of any chronic infection.

[0168] Embodiment 162: The method according to any one of embodiments 100-

161, wherein said therapeutic system comprises identification and treatment of heavy metal toxicity. [0169] Embodiment 163 : The method according to any one of embodiments 100-

162, wherein said therapeutic system comprises identification and treatment of

cardiovascular issues.

[0170] Embodiment 164: The method of embodiment 163, wherein said cardiovascular issues comprise hypertension and/or high cholesterol. [0171] Embodiment 165: The method according to any one of embodiments 163-

164, wherein said method comprises administration of an agent to lower cholesterol. [0172] Embodiment 166: The method of embodiment 165, wherein said agent to lower cholesterol is selected from the group consisting of statins (e.g., atorvastatin

(LIPITOR®), fluvastatin (LESCOL®), lovastatin (MEVACOR®, ALTOPREV™), pravastatin (PRAVACHOL®), rosuvastatin calcium (CRESTOR®), simvastatin

(ZOCOR®) and combinations thereof (e.g. , ADVICOR® (lovastatin + niacin), CADUET® (atorvastatin + amlodipine), VYTORIN™ (simvastatin + ezetimibe), etc.), selective cholesterol absorption inhibitors (e.g., ezetimibe (ZETIA®)), resins (e.g., bile acid sequestrants such as cholestyramine (QUESTRAN®, QUESTRAN® LIGHT,

PREVALITE®, LOCHOLEST®, LOCHOLEST® light), colestipol (Colestid®), colesevelam HC1 (WELCHOL®)), fibrates (e.g. , gemfibrozil (LOPID®), fenofibrate (ANTARA®, LOFIBRA®, TRICOR®, and TRIGLIDE™), clofibrate (ATROMID-S)), niacin (nicotinic acid), o mega-3 fatty acid ethyl esters (e.g., LOVAZA®, VASCEPA™), and marine-derived omega-3 polyunsaturated fatty acids (PUFA).

[0173] Embodiment 167: The method according to any one of embodiments 163- 166, wherein said method comprises administration of an agent to treat hypertension.

[0174] Embodiment 168: The method of embodiment 167, wherein said agent to treat hypertension is selected from the group consisting of thiazide diuretics (e.g., hydrochlorothiazide (MICROZIDE®, CHLORTHALIDONE®), etc.), beta blockers (e.g. acebutolol (SECTRAL®), atenolol (TENORMIN®), etc.), angiotensin-converting enzyme (ACE) inhibitors (e.g., lisinopril (ZESTRIL®), benazepril (LOTENSIN®), captopril (CAPOTEN®), etc.), angiotensin II receptor blockers (ARBs) (e.g., candesartan

(AT AC AND®), losartan (COZAAR®), etc.), calcium channel blockers (e.g., amlodipine (NORVASC®), diltiazem (CARDIZEM®, TIAZAC®), etc.), renin inhibitors (e.g., Aliskiren (TEKTURNA®), etc.), alpha blockers (e.g., doxazosin (CARDURA®), prazosin (MINIPRESS®), etc.), alpha-beta blockers (e.g., carvedilol (COREG®), labetalol

(TRANDATE®), etc.), central-acting agents (e.g., clonidine (CATAPRES®, KAPVAY®), etc.), guanfacine (INTUNIV®, TENEX®), methyldopa, etc.), vasodilators, and aldosterone antagonists (e.g., spironolactone (ALDACTONE®), eplerenone (INSPRA®), etc.).

[0175] Embodiment 169: A kit for the practice of a method according to any one of embodiments 1-99, or 100-168, said kit comprising the following components: fish oil or omega 3 (DHA); coenzyme Q10; curcumin (turmeric); folic acid; citi choline; and resveratrol; wherein said components are provided in the same or different containers in said kit. [0176] Embodiment 170: The kit of embodiment 169, wherein kit contains a drug for the treatment of MCI, dementia, and/or Alzheimer's disease.

[0177] Embodiment 171 : The kit of embodiment 169, wherein kit contains a drug for the treatment of Alzheimer's disease. [0178] Embodiment 172: The kit according to any one of embodiments 169-171, wherein said kit contains vitamin D3.

[0179] Embodiment 173 : The kit of embodiment 172, wherein said vitamin D supplement is in a dosage form (e.g., a unit dosage form) to provide about 200 IU/day.

[0180] Embodiment 174: The kit according to any one of embodiments 169-173, wherein said kit comprises a vitamin B.

[0181] Embodiment 175 : The kit of embodiment 174, wherein said kit comprises methylcobalamin (vitamin B 12).

[0182] Embodiment 176: The kit of embodiment 174-175, wherein said kit comprised one or more vitamins selected from the group consisting of vitamin B l, vitamin B2, vitamin B3, vitamin B4, vitamin B5, and vitamin B6.

[0183] Embodiment 177: The kit according to any one of embodiments 169-176, wherein said kit comprises fish oil or omega 3 (DHA) in a dosage form (e.g., a unit dosage form) to provide about 250 mg/day.

[0184] Embodiment 178: The kit according to any one of embodiments 169-177, wherein said kit comprises H. erinaceus and/or ALCAR.

[0185] Embodiment 179: The kit of embodiment 178, wherein said H. erinaceus and/or ALCAR is in a unit dosage form to provide about 250 mg/day.

[0186] Embodiment 180: The kit according to any one of embodiments 169-179, wherein said kit comprises one or more agents selected from the group consisting of anti- oxidants tocopherols/tocotrienols, Se, N-acetyl cysteine (NAC), ascorbate, and a-lipoic acid.

[0187] Embodiment 181 : The kit according to any one of embodiments 169-180, wherein said kit comprises coenzyme Q10 in a dosage form (e.g., a unit dosage form) to provide about 200 mg/day. [0188] Embodiment 182: The kit according to any one of embodiments 169-181, wherein said kit comprises turmeric (curcumin) in a dosage form (e.g., a unit dosage form) to provide about 400 mg/day.

[0189] Embodiment 183 : The kit according to any one of embodiments 169-182, wherein said kit comprises folic acid in a dosage form to provide about 0.8 mg

methyltetrahydrofolate daily.

[0190] Embodiment 184: The kit according to any one of embodiments 169-183, wherein said kit comprises citicholine in a dosage form (e.g., a unit dosage form) to provide about 500 mg po. [0191] Embodiment 185 : The kit according to any one of embodiments 169-184, wherein said kit comprises alpha glycerophosphorylcholine (alpha-GPC) in a dosage form (e.g., a unit dosage form) to provide about 250 mg po.

[0192] Embodiment 186: The kit according to any one of embodiments 169-185, wherein said kit comprises Bacopa monniera, and/or pantothenic acid, and/or magnesium threonate and/or magnesium glycinate.

[0193] Embodiment 187: The kit of embodiment 186, wherein said kit comprises

Bacopa monniera in a dosage form (e.g., a unit dosage form) to provide about 250mg daily.

[0194] Embodiment 188: The kit according to any one of embodiments 169-187, wherein said kit comprises ashwagandha and/or curcumin. [0195] Embodiment 189: The kit of embodiment 188, wherein said kit comprises ashwagandha in a dosage form (e.g., a unit dosage form) to provide about 500mg daily.

[0196] Embodiment 190: The kit of embodiment 188, wherein kit comprises curcumin in a dosage form (e.g., a unit dosage form) to provide about 400mg daily.

[0197] Embodiment 191 : The kit according to any one of embodiments 169-190, wherein said kit comprises melatonin.

[0198] Embodiment 192: The kit of embodiment 191, wherein said kit comprises melatonin in a dosage form (e.g., a unit dosage form) to provide about 0.5 mg qhs.

[0199] Embodiment 193 : The kit according to any one of embodiments 169-192, wherein said kit comprises tryptophan. [0200] Embodiment 194: The kit of embodiment 193, wherein said tryptophan is in a dosage form (e.g., a unit dosage form) to provide about 500 mg. [0201] Embodiment 195: The kit according to any one of embodiments 169-194, wherein said kit comprises caffeine.

[0202] Embodiment 196: The kit according to any one of embodiments 169-195, wherein said kit contains agents to lower cholesterol and/or to treat hypertension. [0203] Embodiment 197: The kit of embodiment 196, wherein kit comprises an an agent to lower cholesterol.

[0204] Embodiment 198: The kit of embodiment 197, wherein said agent to lower cholesterol is selected from the group consisting of statins (e.g., atorvastatin (LIPITOR®), fluvastatin (LESCOL®), lovastatin (MEVACOR®, ALTOPREV™), pravastatin

(PRAVACHOL®), rosuvastatin calcium (CRESTOR®), simvastatin (ZOCOR®) and combinations thereof (e.g., ADVICOR® (lovastatin + niacin), CADUET® (atorvastatin + amlodipine), VYTORIN™ (simvastatin + ezetimibe), etc.), selective cholesterol absorption inhibitors (e.g., ezetimibe (ZETIA®)), resins (e.g., bile acid sequestrants such as cholestyramine (QUESTRAN®, QUESTRAN® LIGHT, PREVALITE®, LOCHOLEST®, LOCHOLEST® light), colestipol (Colestid®), colesevelam HC1 (WELCHOL®)), fibrates (e.g., gemfibrozil (LOPID®), fenofibrate (ANTARA®, LOFIBRA®, TRICOR®, and TRIGLIDE™), clofibrate (ATROMID-S)), niacin (nicotinic acid), o mega-3 fatty acid ethyl esters (e.g., LOVAZA®, VASCEPA™), and marine-derived omega-3 polyunsaturated fatty acids (PUFA). [0205] Embodiment 199: The kit according to any one of embodiments 196-198, wherein said kit comprises an agent to treat hypertension.

[0206] Embodiment 200: The kit of embodiment 199, wherein said agent to treat hypertension is selected from the group consisting of thiazide diuretics (e.g.,

hydrochlorothiazide (MICROZIDE®, CHLORTHALIDONE®), etc.), beta blockers (e.g. acebutolol (SECTRAL®), atenolol (TENORMIN®), etc.), angiotensin-converting enzyme (ACE) inhibitors (e.g., lisinopril (ZESTRIL®), benazepril (LOTENSIN®), captopril (CAPOTEN®), etc.), angiotensin II receptor blockers (ARBs) (e.g., candesartan

(AT AC AND®), losartan (COZAAR®), etc.), calcium channel blockers (e.g., amlodipine (NORVASC®), diltiazem (CARDIZEM®, TIAZAC®), etc.), renin inhibitors (e.g., Aliskiren (TEKTURNA®), etc.), alpha blockers (e.g., doxazosin (CARDURA®), prazosin (MINIPRESS®), etc.), alpha-beta blockers (e.g., carvedilol (COREG®), labetalol

(TRANDATE®), etc.), central-acting agents (e.g., clonidine (CATAPRES®, KAPVAY®), etc.), guanfacine (INTUNIV®, TE EX®), methyldopa, etc.), vasodilators, and aldosterone antagonists (e.g., spironolactone (ALDACTONE®), eplerenone (INSPRA®), etc.).

BRIEF DESCRIPTION OF THE DRAWINGS

[0207] Figure 1 illustrates alternative processing of, and signaling by, APP [5]. [0208] Figure 2 illustrates possible effects of combining MEND and approved AD drugs such as an acetylcholinesterase inhibitor or NMDA antagonist or both.

DETAILED DESCRIPTION

[0209] However, the past few decades of genetic and biochemical research have revealed an extensive network of molecular interactions involved in AD pathogenesis, leading us to believe a network-based therapeutics approach, rather than a single target- based approach, may be feasible and potentially more effective for the treatment of cognitive decline due to Alzheimer's disease.

[0210] Extensive preclinical studies from numerous laboratories have identified multiple pathogenetic targets for potential intervention. These include, in addition to amyloid-β (Αβ) oligomers and tau, inflammatory mediators, apolipoproteins and lipid metabolism factors, hormonal mediators, trophic factors and their receptors, calcium regulatory pathways, axoplasmic transport machinery, neurotransmitters and their receptors, prion protein, and a host of other potential targets. However, one of the drawbacks of these preclinical studies is that many have implicated single pathways, and shown large effects of targeting one pathway, whereas in human studies, such approaches have not been borne out.

[0211] There are several possible inferences from such discrepant results: first, it is possible that it will be necessary to target multiple pathways simultaneously in order to effect an improvement in symptoms and pathophysiology. Second, it is possible that targeting a single pathway will be sufficient, but that earlier intervention will be required. Third, it is possible that all of these seemingly disparate pathways will converge on a single critical pathway, so that either a single targeted therapy or a multi-component, multi- targeted approach may be effective. And fourth, it is possible that neither of these two types of approaches will be sufficient. It is worth noting, however, that it is possible that addressing multiple targets within the network underlying AD pathophysiology may be successful even when each target is affected in a relatively modest way; in other words, the effects of the various targets may be additive, multiplicative, or otherwise synergistic. [0212] Based on a combination of in vitro and in vivo studies, we have advanced a model in which AD results from an imbalance in endogenous plasticity signaling (Fig. 1), (Bredesen and John 92013) EMBO Mol Med. 5: 795-798; Lu et al. (2000) Nat Med. 6: 397- 404; Galvan et al. (2006) Proc. Natl. Acad. Sci. USA, 103 : 7130-7135; Bredesen (2009) Mol. Neurodegener . 4: 27; Bredesen (2013) Prionic Loops, Anti-Prions, and Dependence Receptors in Neurodegeneration. Pp. 1-24 In: Legname GR, Detlev, ed. Prion Research of Stan Prusiner and his Colleagues, Germany: Dusseldorf University Press), and in which the β-amyloid precursor protein (APP) is a mediator of such plasticity-related signaling. Thus the model suggests that AD is analogous to other chronic illnesses such as cancer, osteoporosis, and atherosclerosis. In the case of osteoporosis, osteoblastic signaling is chronically exceeded by osteoclastic signaling, resulting in an age-associated chronic illness featuring loss of bone.

[0213] By analogy, in Alzheimer's disease, there is a fundamental, age-associated imbalance between the dynamically opposed physiological processes that mediate plasticity, i.e., between synaptoblastic and synaptoclastic activity. This signaling involves

physiological mediators of synaptic development, maintenance, repair, and remodeling, including APP, its derivative peptides, ApoE, and tau, and is modulated by all of the many disparate factors associated with Alzheimer's disease. Furthermore, just as for neoplasia, positive feedback selects and amplifies the disease process; however, whereas in

oncogenesis, the positive feedback occurs at the cellular level, in Alzheimer's disease, the positive feedback occurs at the molecular species level, in the form of prionic loops

(Bredesen and John 92013) EMBO Mol Med. 5: 795-798; Bredesen (2009) Mol.

Neurodegener. 4: 27; Bredesen (2013) Prionic Loops, Anti-Prions, and Dependence Receptors in Neurodegeneration. Pp. 1-24 In: Legname GR, Detlev, ed. Prion Research of Stan Prusiner and his Colleagues, Germany: Dusseldorf University Press).

[0214] In support of this model, the four peptides derived from the amyloidogenic processing of β-amyloid precursor protein (APP)-- sAPPp, Αβ, Jcasp, and C31—have been shown to mediate neurite retraction, synaptic inhibition, caspase activation, and

programmed cell death (Lu et a/. (2000) Nat Med. 6: 397-404; Lu et al. (2003) Ann Neurol. 54: 781-789; Bertrand et al. (2001) Mo/. Cell Neurosci. 18: 503-511; Nikolaev et al. (2009) Nature457: 981-989); whereas, in contrast, the two peptides derived from the non- amyloidogenic processing of APP— sAPPa and aCTF— mediate neurite extension, and inhibit Αβ production, caspase activation, and programmed cell death (Guo et al. (1998) Exp. Cell Res. 245: 57-68; Tian et al. (2010) J. Biol. Chem. 2010; 285:32549-32556; Deyts et al. (2012) J Neurosci. 32: 1714-1729). Thus APP appears to function as a molecular switch, mediating plasticity-related processes, and AD is associated, whether causally or incidentally, with an increase in the ratio of the neurite-retractive peptides to the neurite- extending peptides. Reducing this ratio, whether by affecting BACE (β-site APP cleaving enzyme) or other cleavage of APP, appears to mitigate the AD severity (Galvan et al.

(2006) Proc. Natl. Acad. Sci. USA, 103 : 7130-7135; Jonsson et al. (2012) Nature, 488: 96- 99; Bredesen et al. (2010) J. Alzheimer s Dis. 22: 57-63).

[0215] Of particular interest for the development of a therapeutic program whose goal is to correct the hypothesized chronic synaptoblastic:synaptoclastic imbalance is the feedback mechanism: whereas homeostatic (negative) feedback is utilized by biological systems with single goal outcomes (e.g., serum pH) and no requirement for amplification, prionic loop (positive) feedback is utilized by biological systems with multi-goal outcomes and a requirement for rapid amplification (e.g., thrombus formation or, potentially, synapse modulation), and such systems therefore function as molecular switches (Bredesen (2013) Prionic Loops, Anti-Prions, and Dependence Receptors in Neurodegeneration. Pp. 1-24 In: Legname GR, Detlev, ed. Prion Research of Stan Prusiner and his Colleagues, Germany: Dusseldorf University Press). In these latter systems, the positive feedback feature of the systems dictates that the molecular mediators involved, or a subset thereof, beget more of themselves, or enhance their own activities. Thus such amplifying systems are prionic, with the degree of amplification depending on the stability of the molecular species involved. In the case of APP signaling, binding of a trophic ligand such as netrin-1 increases the production of sAPPa (Lourenco et al. (2009) Cell Death Differ. 16: 655-663), which inhibits BACE cleavage (Obregon et al. (2012) Nature Comm. 3 : 777), with the

complementary fragment, aCTF, inhibiting γ-secretase cleavage (Tian et al. (2010) J. Biol. Chem. 2010; 285:32549-32556); thus cleavage at the a-site produces fragments that inhibit cleavage at the β-site and γ-site rather than feeding back to reduce a-site cleavage.

Similarly, cleavage at the β-site and γ-site to produce Αβ feeds back positively to increase APP-C31 production (Lu et al. (2003) J. Neurochem. 87: 733-741), thus favoring the pro- AD, anti-trophic processing of APP. [0216] Moreover, Αβ itself has been shown to exhibit prionic properties (Meyer-

Luehmann et al. (2006) Science, 313 : 1781-1784), although the mechanism by which it does so has not been clarified. Thus APP processing displays positive feedback, and therefore APP and its derivative peptides function as a molecular switch. This has critical implications for therapeutic development, since it offers a mechanism by which a threshold effect occurs. We have taken advantage of this phenomenon to develop drug candidates that increase the anti-AD, trophic APP signaling, while reducing the pro- AD, anti-trophic APP signaling (Spilman et al. (2014) Brain Res. 1551 : 25-44) and enhancing cognition (Zhang et al. (2012) Am. J. Psychiatry, 169: 974-981). [0217] We have found that the manipulation of the plasticity balance that is mediated or reflected by the APP-derivative peptide balance (Fig. 1), whether genetically or pharmacologically, leads to predictable effects on learning and memory. Mutation of the caspase site at Asp664 inhibits the synaptic loss, memory deficits, and dentate gyral atrophy that otherwise occurs in the PDAPP transgenic mouse model of AD (Galvan et al. (2006) Proc. Natl. Acad. Sci. USA, 103 : 7130-7135; Bredesen et al. (2010) J. Alzheimer s Dis. 22 : 57-63; Saganich et al. (2006) J. Neurosci. 26: 13428-13436; Banwait et al. (2008) J.

Alzheimers Dis. 13 : 1-16; Galvan et al. (2008) Behav. Brain Res. 191 :246-255).

Furthermore, knock-in studies of a wild type mouse D664A support the notion that APP is indeed involved fundamentally in plasticity (Kane, et al, unpublished data, 2014). Systems biology and systems therapeutics of AD (MEND).

[0218] The transgenic mouse studies suggest that APP signaling can be manipulated to inhibit AD pathophysiology. However, the mouse models feature mutations in APP or other familial AD-related genes such as presenilin-1, whereas the large majority of patients with AD suffer from sporadic AD, without an APP or PS1 mutation (although the majority do express the ε4 allele of ApoE). Given the many inputs to the APP signaling balance in humans (e.g., estrogen, netrin- 1, Αβ, etc.), and the minimal success with each of many potentially therapeutic agents (e.g., estrogen, melatonin, exercise, vitamin D, curcumin, Ashwagandha, etc.), we believe the pathobiology of AD dictates a system or program rather than a single targeted agent. Successes with other chronic illnesses such as cardiovascular disease, neoplasia, and HIV support the efficacy of multiple-component systems.

[0219] The basic tenets for such a comprehensive therapeutic system may include the following:

[0220] 1) Just as for other chronic illnesses such as atherosclerotic cardiovascular disease, the goal is not simply to normalize metabolic parameters, but rather to optimize them. As an example, a serum homocysteine level of 12 μιηοΙ/L is considered to be within normal limits, but is well documented to be suboptimal (Heijer et al. (2003) Neurobiol. Aging. 24: 307-313). Similar arguments can be made for many other metabolic parameters. [0221] 2) Based on the hypothesis that AD results from an imbalance in an extensive plasticity network, the therapy should address as many of the network

components as possible, with the idea that a combination may create an effect that is more than the sum of the effects of many monotherapeutics (Bredesen and John 92013) EMBO MolMed. 5: 795-798).

[0222] 3) Just as for other chronic illnesses such as osteoporosis, cancer, and cardiovascular disease, the underlying network features a threshold effect, such that, once enough of the network components have been impacted, the pathogenetic process would be halted or reversed. Therefore, even though it is not expected that most patients will be able to follow every single step of the protocol, as long as enough steps are followed to exceed the threshold, that should be sufficient.

[0223] 4) The approach is personalized, based on the contributory laboratory values affecting the plasticity network; and is computationally intensive, since many physiological data points are analyzed, interdependent network-component status is assessed, and many interventions are prioritized to determine the therapeutic program.

[0224] 5) The program is iterative, so that there is continued optimization over time.

[0225] 6) For each network component, the goal is to address it in as physiological a way, and as far upstream, as possible. [0226] In view of the foregoing considerations, the methods described herein contemplate the combination of drugs for diseases characterized by an amyloidogenic process {e.g., MCI, Alzheimer's disease, etc.) with either the comprehensive Metabolic Enhancement for Neurodegeneration (MEND) program or a subset thereof comprising a combination of nutraceutical and vitamin supplements to create a therapeutic system that is predicted to increase the magnitude of efficacy of the AD drug or the duration of efficacy and patient responsiveness. In certain embodiments the drug is an approved {e.g., FDA approved, European Medicines Agency (EMA) approved, etc.) drug for the treatment of MCI and/or Alzheimer's disease.

[0227] The comprehensive MEND program is an approximately 35 point therapeutic program (see, e.g., Table 1, below) that involves dietary changes, brain stimulation, exercise, sleep optimization, supplementation with specific nutraceutical and vitamin supplements, and multiple additional steps that affect brain chemistry. [0228] The first ten patients who have utilized this program include patients with memory loss associated with AD, amnestic mild cognitive impairment (aMCI), or subject cognitive impairment (SCI). Nine of the 10 patients displayed subjective or objective improvement in cognition beginning within 3 to 6 months with the one failure being a patient with late stage AD (see Example 1). Six of the patients had to discontinue working or were struggling with their jobs at the time of start of the program and all were able to return to work or continue working with improved performance after commencement of MEND. Improvements have been sustained, and at this time, the longest patient follow-up is two and one-half years from initial treatment, with sustained and marked improvement. [0229] MEND consists of three key components that support memory enhancement indicated below:

[0230] 1. Nutritional modulation, e.g., by decreasing simple carbohydrates, gluten, and processed food while increasing vegetable, fish, and tocopherol consumption. Further nutritional component include establishing/maintaining probiotic balance, and (if indicated) caffeine and ketogenic intake. Additional, avoidance of food consumption for 12 hours overnight and within three hours of sleep is encouraged.

[0231] 2. Supplementation to balance key vitamin levels such as B and D vitamins along with the following anti-inflammatory agents and agents that modulate synaptic health: curcumin, fish oil, and/or DHA, coenzyme Q, citicholine, and resveratrol.

[0232] 3. Sleep and lifestyle factor modification, including maintenance of

7-8 hours of sleep daily (melatonin and/or tryptophan if needed), and treatment of any existing sleep apnea; observation of strict oral hygiene and resolution of any existing infections; daily exercise; stress reduction (personalized); and brain and sensory stimulation.

[0233] Treatment of mild cognitive impairment (MCI) or Alzheimer's disease (AD) patents with FDA approved drugs for AD such as the acetylcholinesterase (AChE) inhibitors, e.g., donepezil, results in a short term improvement in memory. Over a period of months the effect of the treatment diminishes, and then the patient's memory continues to decline at a rate similar to that before treatment with these agents. Similarly, treatment of MCI or AD patients with the approved N-methyl-D-aspartic acid (NMDA) antagonist memantine (NAMENDA® or NAMENDA XR®)); with an approved acetylcholinesterase (AChE) inhibitor such as donepezil (ARICEPT®), galantamine (RAZADYNE®), or rivastigmine (EXELON®); or with combined memantine and donepezil (NAMZARIC®) slows cognitive decline in some patients, but does not alter the disease course. [0234] We believe the combination of MEND or subsets of MEND (see, e.g., Table

1) with these FDA-approved AChE inhibitors, with the NMDA receptor antagonist memantine, or with the AChE inhibitor/NMDA antagonist would extend and/or enhance the efficacy of these drugs or combination of drugs in MCI or AD patients. This extension and/or enhancement by MEND+Drug(s) might be manifested in two ways as shown in Figure 2: Scenario I, in which there is extended efficacy resulting in a sustained shift in the baseline of disease progression; or Scenario II where there is a significant delay until disease progression.

Table 1 illustrates points of the comprehensive MEND program. The comprehensive MEND program is a therapeutic program that involves dietary changes, brain stimulation, exercise, sleep optimization, supplementation with specific nutraceutical and vitamin supplements, and multiple additional steps that affect brain chemistry.

20. Improve sleep with melatonin (0.5 mg qhs), tryptophan (500 mg, 3 times a week if awakening)

21. Enhance focus & cognition with bacopa monniera 250mg,

Pantothenic acid, magnesium threonate

22. Decrease Abeta with Ashwagandha 500mg, curcumin 400mg/day

23. Increase sleep duration - to at least 7-8 hours, but not more than 9

hours; exclude or treat sleep apnea

24. Balance hormones, including thyroid hormones fT3, and fT4,

estradiol (E2), testosterone (T), progesterone, pregnenolone, Cortisol

25. Brain stimulation - one or more daily puzzles, training software,

reading

26. Strict oral hygiene and care (electric flosser/brusher, address all

dental issues)

27. Exercise - 30 min - 1 hour 4-6 days a week.

28. Treat hearing and/or vision loss (hearing aids, glasses or laser)

29. Lower homocysteine: Methyl cobalamin-vitamin B12, methylfolate,

vitamin B6 (P5 P); trimethylglycine (TMG) if necessary

30. Review all medications & dosages to identify interactions

31. Maintain bone density (see D3 above) with calcium or osteoclast

mediated bone resorption inhibitor if prescribed by physician

32. Identify/treat insulin resistance or diabetes

33. Identify/treat any chronic infection

34. Identify/treat heavy metal toxicity, chelators if necessary; balance

plasma Zn & Cu levels

35. Identify/treat cardiovascular issues, e.g., treat high cholesterol and/or

hypertension

[0235] As evident from the points comprising the comprehensive MEND program, nutritional modulation in the context of MEND refers to an alteration of daily eating habits to fit within the guidelines of the MEND program. Ideally, an initial interview is performed with the patient or enrollee in the program and a food diary is kept for one month. Based on analysis of the diary, recommendations will be made as to alterations in consumed food and beverages. As the patient/enrollee enters the program a strict diary of food consumption will be optional but optimal; alternatively the patient/enrollee will be interviewed at each visit to allow optimization of diet. In various embodiments MEND is a physician- or healthcare- provider supervised program and that provider will aid in determination of nutritional modulation.

[0236] Some supplementation will be used if levels of certain nutrients are determined to be low in blood or plasma, some will be used routinely and levels not determined. For example, if an individual's B12 blood levels are normal, supplementation will not be added. If levels are not available or if levels are low, supplementation will be added, e.g., at the dose described in Table 1.

[0237] In certain embodiments vegetable, fish and tocopherol consumption is increased. For example, vegetable servings can be adjusted to at least three per day.

Additional one serving per day of a food rich in tocopherols can be incorporated into the diet. Such foods include - but are not limited to - tofu, spinach, nuts, etc. Typically, fish consumption will be adjusted to at least about three times per week.

[0238] As noted in Table 1, in various embodiments, MEND can involve a decrease in consumption of simple carbohydrates, gluten and processed food. In particular, an attempt should be made to: 1) Completely eliminate simple carbohydrates; 2) Completely eliminate gluten; at a maximum simple carbohydrate and/or gluten-containing foods should only be consumed three or four times a week; 3) Processed food should be reduced to no more than one serving a day. Processed food in this context refers to boxed, canned, or bagged food to which anything has been added, including sugar, salt, dyes, additives, preservatives, flavor enhancer fats, etc. Unaltered food that is packaged, for example fresh frozen fruits or vegetables, unaltered rice in a bag or box or similar foods in their natural but perhaps frozen or dried state is acceptable in MEND. Food cooked at home or food prepared at home to which herbs or fats such as coconut oil is added is not defined as processed for the purposes of MEND. [0239] In various embodiments MEND involves the establishment and/or maintenance of a probiotic balance. Probiotic balance typically can be maintained by daily consumption of a probiotic, or once a day consumption of kefir or yogurt.

[0240] In certain embodiments MEND involves supplementation is vitamins B, D, and certain other vitamins. Ideally, blood levels of B12 will be determined for each individual, if levels are below the normal range (200 - 900 pg/mL) daily supplementation will be initiated using timed-released 1000 μg (meg) tablets once a day followed by monthly retesting of blood until levels are at least above 200pg/ml, with a goal of 400-900 pg/ml; that is, an attempt will be made to optimize vitamin levels rather than simply bringing them within the normal range. If levels are not available, supplementation at the levels described below in the list will be added. Similarly for D3, ideally levels will be determined and supplementation added as needed, and again if levels are not available, supplementation should be used as described below. [0241] As noted in Table 1, MEND can involve treatment of cardiac disease, in particular hypertension and/or high cholesterol. High cholesterol can be treated with the use of cholesterol-lowering drugs. Such drugs include, but are not limited to, statins (e.g., atorvastatin (LIPITOR®), fluvastatin (LESCOL®), lovastatin (MEVACOR®,

ALTOPREV™), pravastatin (PRAVACHOL®), rosuvastatin calcium (CRESTOR®), simvastatin (ZOCOR®) and combinations thereof (e.g., ADVICOR® (lovastatin + niacin), CADUET® (atorvastatin + amlodipine), VYTORIN™ (simvastatin + ezetimibe), etc.), selective cholesterol absorption inhibitors (e.g., ezetimibe (ZETIA®)), resins (e.g., bile acid sequestrants such as cholestyramine (QUESTRAN®, QUESTRAN® LIGHT,

PREVALITE®, LOCHOLEST®, LOCHOLEST® light), colestipol (Colestid®), colesevelam HC1 (WELCHOL®)), fibrates (e.g., gemfibrozil (LOPID®), fenofibrate (ANTARA®, LOFIBRA®, TRICOR®, and TRIGLIDE™), clofibrate (ATROMID-S)), niacin (nicotinic acid), o mega-3 fatty acid ethyl esters (e.g., LOVAZA®, VASCEPA™), marine-derived omega-3 polyunsaturated fatty acids (PUPA), and the like. [0242] Similarly, hypertension can be treated with any of a variety of drugs including, but not limited to, thiazide diuretics (e.g., hydrochlorothiazide (MICROZIDE®, CHLORTHALIDONE®), etc.), beta blockers (e.g. acebutolol (SECTRAL®), atenolol (TENORMIN®), etc.), angiotensin-converting enzyme (ACE) inhibitors (e.g., lisinopril (ZESTRIL®), benazepril (LOTENSIN®), captopril (CAPOTEN®), etc.), angiotensin II receptor blockers (ARBs) (e.g., candesartan (AT AC AND®), losartan (COZAAR®), etc.), calcium channel blockers (e.g., amlodipine (NORVASC®), diltiazem (CARDIZEM®, TIAZAC®), etc.), renin inhibitors (e.g., Aliskiren (TEKTURNA®), etc.), alpha blockers (e.g., doxazosin (CARDURA®), prazosin (MINIPRESS®), etc.), alpha-beta blockers (e.g., carvedilol (COREG®), labetalol (TRANDATE®), etc.), central-acting agents (e.g., clonidine (CATAPRES®, KAPVAY®), etc.), guanfacine (INTUNIV®, TENEX®), methyldopa, etc.), vasodilators, and aldosterone antagonists (e.g., spironolactone

(ALDACTONE®), eplerenone (INSPRA®), etc.), and the like.

MEND or MEND subsets in combination with Alzheimer's Disease Drugs.

[0243] In certain embodiments, MEND, or subsets thereof, for use in combination with drugs for the treatment of Alzheimer's disease are provided. An illustrative, but non- limiting list of approved drugs is shown in Table 2.

Table 2. FDA approved drugs for the treatment of Alzheimer's disease. Generic Brand Approved For

donepezil ARICEPT® AD all stages

galantamine RAZADYNE® Mild to moderate AD

memantine NAMENDA® Moderate to severe AD

rivastigmine EXELON® Mild to moderate AD

tacrine COGNEX® Mild to moderate AD

Donezepil + Namzaric®

memantine

[0244] In certain embodiments, MEND, or subsets thereof, is contemplated for use in combination with drugs in development for the treatment of Alzheimer's disease and/or MCI. Illustrative, but non-liming examples of such therapeutic agents include, but are not limited to disulfiram and/or analogs thereof, honokiol and/or analogs thereof, tropisetron and/or analogs thereof, nimetazepam and/or analogues thereof (see, e.g., USSN 13/213,960 (U.S. Patent Publication No: US-2012-0071468-A1), and PCT/US2011/048472 (PCT Publication No: WO 2012/024616) which are incorporated herein by reference for the compounds described therein), tropinol esters and/or related esters and/or analogs thereof (see, e.g., PCT Pub. No: WO 2013/019901 A2 (PCT/US2012/049223), which is incorporated herein by reference for the compounds described herein), TrkA kinase inhibitors (e.g., ADDN-1351) and/or analogs thereof (see, e.g., PCT Pub. No: WO

2013/026021 A2 (PCT/US2012/051426) which is incorporated herein by reference for the compounds described therein), D2 receptor agonists and alpha 1 -adrenergic receptor antagonists, and APP-specific BACE Inhibitors (ASBIs) as described and/or claimed in PCT Pub. No: WO 2013/142370 Al (PCT/US2013/032481) which is incorporated herein by reference for the active agents described herein including, but not limited to galangin, a galangin prodrug, rutin, a rutin prodrug, and other flavonoids and flavonoid prodrugs as described or claimed therein, hydantoins as described in PCT Pub. No: WO2014127042 Al (PCT/US2014/016100), which is incorporated herein by reference for the hydantoins described herein, and the like.

[0245] Other drugs in development for treatment of Alzheimer's disease, and /or

MCI include, for example colostrinin, a proline-rich polypeptide complex derived from sheep colostrum (O-CLN; ReGen Therapeutics, London, UK). Colostrinin inhibits Αβ aggregation and neurotoxicity in cellular assays and improves cognitive performance in animal models. Another illustrative, but non-limiting drug is Alzhemed (3 -amino- 1- propanesulfonic acid) an Αβ aggregation inhibitor drug. Another illustrative, but non- limiting drug is scyllo-inositol which is able to stabilize oligomeric aggregates of Αβ and inhibit Αβ toxicity in mouse hippocampus.

[0246] Other drugs in development also include, but are not limited to antibodies that bind to Αβ-42 (see, e.g., solanezumab or babinezumab) or to the oligomers formed by Αβ (e.g., cernezumab, gantenerumab). Other drugs include, but are not limited to Αβ vaccines including, but not limited to CAD-106, UB311, V950, and the like.

[0247] Other drugs include, but are not limited to chelators of Zn and/or Cu. PBT2 is one illustrative, but non-limiting second -generation 8-OH quinoline metal-protein- attenuating compound that affects the Cu2+-mediated and Zn2+-mediated toxic

oligomerization of Αβ.

[0248] In certain embodiments MEND may also be used in combination with various selective Aβ42-lowering agents. Illustrative, but non-limiting examples include BACE1, (e.g., MK-8931, AZD-3839 or CTS-21166), y-secretase inhibitors (e.g., semagacestat (LY-450139), tarenflurbil (or R-flurbiprofen), BMS-708163 (avagacestat; Bristol-Myers Squibb, New York, NY, USA), and the like, a-secretase potentiators

(e.g.bryostatin-1 , Etazolate (EHT 0202; ExonHit Therapeutics, Paris, France), and the like.

[0249] In certain embodiments MEND may be used in combination with modulators of tau deposition (e.g. LMTX from TauRx) and/or phosphorylation, including inter alia pyrazolopyrazines, pyrazolopyri dines, the aminothiazole AR-A014418, and sodium valproate.

[0250] In certain embodiments MEND may be used in combination with drugs that increase sAPPa. Such drugs include, but are not limited to Tropisetron, C41, PRX03140, Biyostatin-1, and the like. [0251] In certain embodiments MEND may be used in combination with drugs that are alpha7 nicotinic receptor agonists. Such drugs include, but are not limited to MEM- 3454, EVP-6124, and the like.

[0252] In certain embodiments MEND may be used in combination with drugs that are 5HT-6 antagonists. Such drugs include, but are not limited to SB742457, and the like. [0253] In certain embodiments MEND may be used in combination with drugs that are phosphodiesterase (PDE9A) inhibitors. Such drugs include, but are not limited to PF- 04447943, and the like. [0254] In certain embodiments MEND may be used in combination with

neuropeptides including, but not limited to Davunetide, humanin and its mimetics, and the like.

[0255] In certain embodiments MEND may be used in combination with

nerotrophic factor therapeutics. Such therapeutics include, but are not limited to NGF, Netrin-1, and/or BDNF, and the like.

[0256] In addition to treatment methods, MEND may also be used in the evaluation of drug candidates for the treatment of AD and/or MCI. MEND may be useful as a platform on which drugs that would fail as monotherapeutics may succeed as key components of a therapeutic system. Therapeutic combination has proven successful in multiple chronic illnesses such as HIV and cancer (Bredesen and John 92013) EMBOMol Med. 5: 795-798).

[0257] Accordingly in certain embodiments, a method of evaluating a drug for the treatment of MCI, dementia, and/or Alzheimer's disease is provided where the method comprises providing a population of subjects having or at risk for MCI, dementia, and/or Alzheimer's disease; administering to the subjects a therapeutic system comprising a comprehensive Metabolic Enhancement for Neurodegeneration (MEND) program or a subset thereof; administering to the subjects said drug that is to be evaluated; and evaluating over time the response of said subjects to said drug. In certain embodiments the evaluating comprises: determining if said drug prevents or delays the transition from a cognitively asymptomatic pre- Alzheimer's condition to a pre- Alzheimer's cognitive dysfunction; and/or determining if said drug prevents or delays the onset of a pre- Alzheimer's cognitive dysfunction; and/or determining if said drug ameliorates one or more symptoms of a pre- Alzheimer's cognitive dysfunction; and/or determining if said drug prevents or delays the progression of a pre- Alzheimer's cognitive dysfunction to Alzheimer's disease; and/or identifying elevated markers of neuronal injury selected from the group consisting of tau, and FDG uptake; and/or detecting a reduction in the CSF of levels of one or more components selected from the group consisting of Αβ42, sAPPp, total-Tau (tTau), phospho- Tau (pTau), APPneo, soluble Αβ40, pTau/Ap42 ratio and tTau/Ap42 ratio, and/or an increase in the CSF of levels of one or more components selected from the group consisting of Αβ42/Αβ40 ratio, Αβ42/Αβ38 ratio, sAPPa, βΑΡΡα/βΑΡΡβ ratio, 8ΑΡΡα/Αβ40 ratio, and 8ΑΡΡα/Αβ42 ratio. Subjects Who Can Benefit from the MEND program

[0258] Subjects/patients amenable to treatment using the comprehensive Metabolic

Enhancement for Neurodegeneration (MEND) program described herein include individuals at risk of disease (e.g., mild cognitive impairment (MCI), dementia, and/or Alzheimer's disease) but not showing symptoms, as well as subjects presently showing symptoms.

Accordingly, certain subjects include subjects at risk for the onset of a pre- Alzheimer's condition and/or cognitive dysfunction (e.g., MCI), and/or subjects diagnosed as having a pre- Alzheimer's condition and/or cognitive dysfunction (e.g., MCI).

[0259] Accordingly, in various embodiments, therapeutic and/or prophylactic methods are provided that utilized the comprehensive Metabolic Enhancement for

Neurodegeneration (MEND) program described herein, in certain embodiments in combination with a drug for the treatment of MCI, dementia, and/or Alzheimer's disease.

Prophylaxis

[0260] In certain embodiments, the MEND program described herein, in certain embodiments in combination with a drug for the treatment of MCI, dementia, and/or Alzheimer's disease, is utilized in various prophylactic contexts. Thus, for example, in certain embodiments, the MEND program alone or in combination with one or more drugs as described herein can be used to prevent or delay the onset of a pre- Alzheimer's cognitive dysfunction, and/or to ameliorate one more symptoms of a pre- Alzheimer's condition and/or cognitive dysfunction, and/or to prevent or delay the progression of a pre- Alzheimer's condition and/or cognitive dysfunction to Alzheimer's disease.

[0261] Accordingly in certain embodiments, the methods described herein are contemplated for subjects identified as "at risk" and/or as having evidence of early

Alzheimer's Disease (AD) pathological changes, but who do not meet clinical criteria for MCI or dementia. Without being bound to a particular theory, it is believed that even this "preclinical" stage of the disease represents a continuum from completely asymptomatic individuals with biomarker evidence suggestive of AD-pathophysiological process(es) (abbreviated as AD-P, see, e.g., Sperling et al, (2011) Alzheimer 's & Dementia, 1-13) at risk for progression to AD dementia to biomarker-positive individuals who are already demonstrating very subtle decline but not yet meeting standardized criteria for MCI (see, e.g., Albert et al, (2011) Alzheimer's and Dementia, 1-10 (doi : 10.1016/j j alz.2011.03.008)).

[0262] This latter group of individuals might be classified as "not normal, not MCI" but can be designated "pre-symptomatic" or "pre-clinical or "asymptomatic" or "premanifest"). In various embodiments, this continuum of pre- symptomatic AD can also encompass (1) individuals who carry one or more apolipoprotein E (APOE) ε4 alleles who are known or believed to have an increased risk of developing AD dementia, at the point they are AD-P biomarker-positive, and (2) carriers of autosomal dominant mutations, who are in the presymptomatic biomarker-positive stage of their illness, and who will almost certainly manifest clinical symptoms and progress to dementia.

[0263] A biomarker model has been proposed in which the most widely validated biomarkers of AD-P become abnormal and likewise reach a ceiling in an ordered manner {see, e.g., Jack et al, (2010) Lancet Neurol, 9: 119-128.). This biomarker model parallels proposed pathophysiological sequence of (pre- AD/ AD), and is relevant to tracking the preclinical (asymptomatic) stages of AD (see, e.g., Figure 3 in Sperling et al, (2011) Alzheimer 's & Dementia, 1-13). Biomarkers of brain amyloidosis include, but are not limited to reductions in CSF Αβ ₄₂ and increased amyloid tracer retention on positron emission tomography (PET) imaging. Elevated CSF tau is not specific to AD and is thought to be a biomarker of neuronal injury. Decreased fluorodeoxyglucose 18F (FDG) uptake on PET with a temporoparietal pattern of hypometabolism is a biomarker of AD- related synaptic dysfunction. Brain atrophy on structural magnetic resonance imaging (MRI) in a characteristic pattern involving the medial temporal lobes, paralimbic and temporoparietal cortices is a biomarker of AD-related neurodegeneration. Other markers include, but are not limited to volumetric MRI, FDG-PET, or plasma biomarkers (see, e.g., Vemuri et al, (2009) Neurology, 73 : 294-301; Yaffe et al, (2011) JAMA 305: 261-266).

[0264] In certain embodiments, the subjects suitable for the prophylactic methods incorporating MEND include, but are not limited to subject characterized as having asymptomatic cerebral amyloidosis. In various embodiments, these individuals have biomarker evidence of Αβ accumulation with elevated tracer retention on PET amyloid imaging and/or low Αβ42 in CSF assay, but typically no detectable evidence of additional brain alterations suggestive of neurodegeneration or subtle cognitive and/or behavioral symptomatology.

[0265] It is noted that currently available CSF and PET imaging biomarkers of Αβ primarily provide evidence of amyloid accumulation and deposition of fibrillar forms of amyloid. Data suggest that soluble or oligomeric forms of Αβ are likely in equilibrium with plaques, which may serve as reservoirs. In certain embodiments, it is contemplated that there is an identifiable preplaque stage in which only soluble forms of Αβ are present. In certain embodiments, it is contemplated that oligomeric forms of amyloid may be critical in the pathological cascade, and provide useful markers. In addition, early synaptic changes may be present before evidence of amyloid accumulation.

[0266] In certain embodiments, the subjects suitable for the prophylactic methods contemplated herein include, but are not limited to, subjects characterized as amyloid positive with evidence of synaptic dysfunction and/or early neurodegeneration. In various embodiments, these subjects have evidence of amyloid positivity and presence of one or more markers of "downstream" AD-P-related neuronal injury. Illustrative, but non-limiting markers of neuronal injury include, but are not limited to (1) elevated CSF tau or phospho- tau, (2) hypometabolism in an AD-like pattern {e.g., posterior cingulate, precuneus, and/or temporoparietal cortices) on FDG-PET, and (3) cortical thinning/gray matter loss in a specific anatomic distribution {e.g., lateral and medial parietal, posterior cingulate, and lateral temporal cortices) and/or hippocampal atrophy on volumetric MRI. Other markers include, but are not limited to fMRI measures of default network connectivity. In certain embodiments, early synaptic dysfunction, as assessed by functional imaging techniques such as FDG-PET and fMRI, can be detectable before volumetric loss. Without being bound to a particular theory, it is believed that amyloid-positive individuals with evidence of early neurodegeneration may be farther down the trajectory {e.g., in later stages of preclinical (asymptomatic) AD). [0267] In certain embodiments, the subjects suitable for the prophylactic methods contemplated herein include, but are not limited to, subjects characterized as amyloid positive with evidence of neurodegeneration and subtle cognitive decline. Without being bound to a particular theory, it is believed that those individuals with biomarker evidence of amyloid accumulation, early neurodegeneration, and evidence of subtle cognitive decline are in the last stage of preclinical (asymptomatic) AD, and are approaching the border zone with clinical criteria for mild cognitive impairment (MCI). These individuals may demonstrate evidence of decline from their own baseline (particularly if proxies of cognitive reserve are taken into consideration), even if they still perform within the "normal" range on standard cognitive measures. Without being bound to a particular theory, it is believed that more sensitive cognitive measures, particularly with challenging episodic memory measures, may detect very subtle cognitive impairment in amyloid-positive individuals. In certain embodiments, criteria include, but are not limited to, self-complaint of memory decline or other subtle neurobehavioral changes. [0268] As indicated above, subjects/patients amenable to prophylactic methods described herein incorporating a MEND protocol include individuals at risk of disease (e.g., a pathology characterized by amyloid plaque formation such as MCI) but not showing symptoms, as well as subjects presently showing certain symptoms or markers. It is known that the risk of MCI and later Alzheimer's disease generally increases with age.

Accordingly, in asymptomatic subjects with no other known risk factors, in certain embodiments, prophylactic application is contemplated for subjects over 50 years of age, or subjects over 55 years of age, or subjects over 60 years of age, or subjects over 65 years of age, or subjects over 70 years of age, or subjects over 75 years of age, or subjects over 80 years of age, in particular to prevent or slow the onset or ultimate severity of mild cognitive impairment (MCI), and/or to slow or prevent the progression from MCI to early stage Alzheimer's disease (AD).

[0269] In certain embodiments, the methods described herein present methods are especially useful for individuals who do have a known genetic risk of Alzheimer's disease (or other amyloidogenic pathologies), whether they are asymptomatic or showing symptoms of disease. Such individuals include those having relatives who have experienced MCI or AD (e.g., a parent, a grandparent, a sibling), and those whose risk is determined by analysis of genetic or biochemical markers. Genetic markers of risk toward Alzheimer's disease include, for example, mutations in the APP gene, particularly mutations at position 717 and positions 670 and 671 referred to as the Hardy and Swedish mutations respectively (see, e.g., Hardy (1997) Trends. Neurosci., 20: 154-159). Other markers of risk include mutations in the presenilin genes (PS1 and PS2), family history of AD, having the familial Alzheimer's disease (FAD) mutation, the APOE ε4 allele, hypercholesterolemia or atherosclerosis. Further susceptibility genes for the development of Alzheimer's disease are reviewed, e.g., in Sleegers, et al, (2010) Trends Genet. 26(2): 84-93.

[0270] In some embodiments, the subject is asymptomatic but has familial and/or genetic risk factors for developing MCI or Alzheimer's disease. In asymptomatic patients, treatment can begin at any age (e.g., 20, 30, 40, 50, years of age). Usually, however, it is not necessary to begin treatment until a patient reaches at least about 40, 50, 60, 70 or 80 years of age.

[0271] In some embodiments, the subject is one who exhibits symptoms, for example, of mild cognitive impairment (MCI) or Alzheimer's disease (AD). Individuals presently suffering from Alzheimer's disease can be recognized from characteristic dementia, as well as the presence of risk factors described above. In addition, a number of diagnostic tests are available for identifying individuals who have AD. These include, but are not limited to measurement of CSF Tau, phospho-tau (pTau), Αβ42 levels and C- terminally cleaved APP fragment (APPneo). Elevated total-Tau (tTau), phospho-Tau (pTau), APPneo, soluble Αβ40, pTau/Ap42 ratio and tTau/Ap42 ratio, and decreased Αβ42 levels, Αβ42/Αβ40 ratio, Αβ42/Αβ38 ratio, sAPPa levels, βΑΡΡα/βΑΡΡβ ratio, 8ΑΡΡα/Αβ40 ratio, and sAPPa 542 ratio signify the presence of AD. In some embodiments, the subject or patient is clinically diagnosed as having MCI. Increased levels of neural thread protein (NTP) in urine and/or increased levels of a2-macroglobulin (a2M) and/or complement factor H (CFH) in plasma are also biomarkers of MCI and/or AD (see, e.g., Anoop et al, (2010) Int. J. Alzheimer's Dis.20\0:606802).

[0272] In certain embodiments, subjects amenable to treatment may have age- associated memory impairment (AAMI), or mild cognitive impairment (MCI). The methods described herein are particularly well-suited to the prophylaxis and/or treatment of MCI, particularly MCI characterized by an amyloidogenic process. In such instances, the methods can delay or prevent the onset of MCI, and or reduce one or more symptoms characteristic of MCI and/or delay or prevent the progression from MCI to early-, mid- or late- stage Alzheimer's disease, and/or reduce the ultimate severity of the disease. In certain embodiments use of the MEND program alone, or in combination with a drug for the treatment of mild cognitive impairment (MCI), dementia, and/or Alzheimer's disease delays the onset of disease for a longer period of time than use of the drug alone and/or reduces the severity of the disease than the severity observed when the drug is used alone.

Mild Cognitive Impairment (MCI)

[0273] In various embodiments, the MEND program, alone or in combination with various drugs for the treatment of mild cognitive impairment (MCI), dementia, and/or Alzheimer's disease, can be used for the treatment and/or prophylaxis of age-related cognitive decline and/or for the treatment and/or prophylaxis of mild cognitive impairment (MCI). Mild cognitive impairment, also known as incipient dementia, or isolated memory impairment) is a diagnosis given to individuals who have cognitive impairments beyond that expected for their age and education, but that typically do not interfere significantly with their daily activities (see, e.g., Petersen et al, (1999) Arch. Neurol. 56(3): 303-308). It is considered in many instances to be a boundary or transitional stage between normal aging and dementia. Although MCI can present with a variety of symptoms, when memory loss is the predominant symptom it is termed "amnestic MCI" and is can be a risk factor for Alzheimer's disease (see, e.g., Grundman et al, (2004) Arch. Neurol. 61(1): 59-66; and on the internet at en.wikipedia.org/wiki/Mild_cognitive_impairment - cite_note-Grundman-l). When individuals have impairments in domains other than memory it is often classified as non-amnestic single- or multiple-domain MCI and these individuals are believed to be more likely to convert to other dementias {e.g. dementia with Lewy bodies). There is evidence suggesting that while amnestic MCI patients may not meet neuropathologic criteria for Alzheimer's disease, patients may be in a transitional stage of evolving Alzheimer's disease; patients in this hypothesized transitional stage demonstrated diffuse amyloid in the neocortex and frequent neurofibrillary tangles in the medial temporal lobe (see, e.g., Petersen et al, (2006) Arch. Neurol, 63(5): 665-72).

[0274] The diagnosis of MCI typically involves a comprehensive clinical assessment including clinical observation, neuroimaging, blood tests and

neuropsychological testing. In certain embodiments, diagnostic criteria for MCI include, but are not limited to those described by Albert et al, (201 1) Alzheimer 's & Dementia. 1- 10. As described therein, diagnostic criteria include (1) core clinical criteria that could be used by healthcare providers without access to advanced imaging techniques or

cerebrospinal fluid analysis, and (2) research criteria that could be used in clinical research settings, including clinical trials. The second set of criteria incorporate the use of biomarkers based on imaging and cerebrospinal fluid measures. The final set of criteria for mild cognitive impairment due to AD has four levels of certainty, depending on the presence and nature of the biomarker findings.

[0275] In certain embodiments, clinical evaluation/diagnosis of MCI involves: (1)

Concern reflecting a change in cognition reported by patient or informant or clinician {e.g., historical or observed evidence of decline over time); (2) Objective evidence of Impairment in one or more cognitive domains, typically including memory {e.g., formal or bedside testing to establish level of cognitive function in multiple domains); (3) Preservation of independence in functional abilities; (4) Not demented; and in certain embodiments, (5) An etiology of MCI consistent with AD pathophysiological processes. Typically vascular, traumatic, medical causes of cognitive decline are ruled out where possible. In certain embodiments, evidence of longitudinal decline in cognition is identified, when feasible. Diagnosis is reinforced by a history consistent with AD genetic factors, where relevant. [0276] With respect to impairment in cognitive domain(s), there should be evidence of concern about a change in cognition, in comparison with the person's previous level. There should be evidence of lower performance in one or more cognitive domains that is greater than would be expected for the patient's age and educational background. If repeated assessments are available, then a decline in performance should be evident over time. This change can occur in a variety of cognitive domains, including memory, executive function, attention, language, and visuospatial skills. An impairment in episodic memory (e.g., the ability to learn and retain new information) is seen most commonly in MCI patients who subsequently progress to a diagnosis of AD dementia. [0277] With respect to preservation of independence in functional abilities, it is noted that persons with MCI commonly have mild problems performing complex functional tasks which they used to perform shopping. They may take more time, be less efficient, and make more errors at performing such activities than in the past. Nevertheless, they generally maintain their independence of function in daily life, with minimal aids or assistance.

[0278] With respect to dementia, the cognitive changes should be sufficiently mild that there is no evidence of a significant impairment in social or occupational functioning. If an individual has only been evaluated once, change will be inferred from the history and/or evidence that cognitive performance is impaired beyond what would have been expected for that individual.

[0279] Cognitive testing is optimal for objectively assessing the degree of cognitive impairment for an individual. Scores on cognitive tests for individuals with MCI are typically 1 to 1.5 standard deviations below the mean for their age and education matched peers on culturally appropriate normative data (e.g., for the impaired domain(s), when available).

[0280] Episodic memory (i.e., the ability to learn and retain new information) is most commonly seen in MCI patients who subsequently progress to a diagnosis of AD dementia. There are a variety of episodic memory tests that are useful for identifying those MCI patients who have a high likelihood of progressing to AD dementia within a few years. These tests typically assess both immediate and delayed recall, so that it is possible to determine retention over a delay. Many, although not all, of the tests that have proven useful in this regard are wordlist learning tests with multiple trials. Such tests reveal the rate of learning over time, as well as the maximum amount acquired over the course of the learning trials. They are also useful for demonstrating that the individual is, in fact, paying attention to the task on immediate recall, which then can be used as a baseline to assess the relative amount of material retained on delayed recall. Examples of such tests include (but are not limited to: the Free and Cued Selective Reminding Test, the Rey Auditory Verbal Learning Test, and the California Verbal Learning Test. Other episodic memory measures include, but are not limited to: immediate and delayed recall of a paragraph such as the Logical Memory I and II of the Wechsler Memory Scale Revised (or other versions) and immediate and delayed recall of nonverbal materials, such as the Visual Reproduction subtests of the Wechsler Memory Scale-Revised I and II. [0281] Because other cognitive domains can be impaired among individuals with

MCI, it is desirable to examine domains in addition to memory. These include, but are not limited to executive functions (e.g., set-shifting, reasoning, problem-solving, planning), language (e.g., naming, fluency, expressive speech, and comprehension), visuospatial skills, and attentional control (e.g., simple and divided attention). Many clinical

neuropsychological measures are available to assess these cognitive domains, including (but not limited to the Trail Making Test (executive function), the Boston Naming Test, letter and category fluency (language), figure copying (spatial skills), and digit span forward (attention).

[0282] As indicated above, genetic factors can be incorporated into the diagnosis of MCI. If an autosomal dominant form of AD is known to be present (e.g., mutation in APP, PS1, PS2), then the development of MCI is most likely the precursor to AD dementia. The large majority of these cases develop early onset AD (e.g., onset below 65 years of age).

[0283] In addition, there are genetic influences on the development of late onset AD dementia. For example, the presence of one or two ε4 alleles in the apolipoprotein E (APOE) gene is a genetic variant broadly accepted as increasing risk for late-onset AD dementia. Evidence suggests that an individual who meets the clinical, cognitive, and etiologic criteria for MCI, and is also APOE ε4 positive, is more likely to progress to AD dementia within a few years than an individual without this genetic characteristic. It is believed that additional genes play an important, but smaller role than APOE and also confer changes in risk for progression to AD dementia (see, e.g., Bertram et al, (2010) Neuron, 21 : 270-281).

[0284] In certain embodiments, subjects suitable for the prophylactic methods described herein (e.g., administration of the MEND program alone or in combination with a drug for the treatment of MCI, dementia, and/or Alzheimer's disease) include, but need not be limited to subjects identified having one or more of the core clinical criteria described above and/or subjects identified with one or more "research criteria" for MCI, e.g., as described below. [0285] "Research criteria" for the identification/prognosis of MCI include, but are not limited to biomarkers that increase the likelihood that MCI syndrome is due to the pathophysiological processes of AD. Without being bound to a particular theory, it is believed that the conjoint application of clinical criteria and biomarkers can result in various levels of certainty that the MCI syndrome is due to AD pathophysiological processes. In certain embodiments, two categories of biomarkers have been the most studied and applied to clinical outcomes are contemplated. These include "Αβ" (which includes CSF Αβ ₄₂ and/or PET amyloid imaging) and "biomarkers of neuronal injury" (which include, but are not limited to CSF tau/p-tau, hippocampal, or medial temporal lobe atrophy on MRI, and temporoparietal/ precuneus hypometabolism or hypoperfusion on PET or SPECT). [0286] Without being bound to a particular theory, it is believed that evidence of both Αβ, and neuronal injury (either an increase in tau/p-tau or imaging biomarkers in a topographical pattern characteristic of AD), together confers the highest probability that the AD pathophysiological process is present. Conversely, if these biomarkers are negative, this may provide information concerning the likelihood of an alternate diagnosis. It is recognized that biomarker findings may be contradictory and accordingly any biomarker combination is indicative (an indicator) used on the context of a differential diagnosis and not itself dispositive. It is recognized that varying severities of an abnormality may confer different likelihoods or prognoses, that are difficult to quantify accurately for broad application. [0287] For those potential MCI subjects whose clinical and cognitive MCI syndrome is consistent with AD as the etiology, the addition of biomarker analysis effects levels of certainty in the diagnosis. In the most typical example in which the clinical and cognitive syndrome of MCI has been established, including evidence of an episodic memory disorder and a presumed degenerative etiology, the most likely cause is the neurodegenerative process of AD. However, the eventual outcome still has variable degrees of certainty. The likelihood of progression to AD dementia will vary with the severity of the cognitive decline and the nature of the evidence suggesting that AD pathophysiology is the underlying cause. Without being bound to a particular theory it is believed that positive biomarkers reflecting neuronal injury increase the likelihood that progression to dementia will occur within a few years and that positive findings reflecting both Ab accumulation and neuronal injury together confer the highest likelihood that the diagnosis is MCI due to AD.

[0288] A positive Αβ biomarker and a positive biomarker of neuronal injury provide an indication that the MCI syndrome is due to AD processes and the subject is well suited for the methods described herein (e.g., treatment the MEND program alone or in combination with a rug for the treatment of MCI, dementia, and/or Alzheimer's disease)).

[0289] A positive Αβ biomarker in a situation in which neuronal injury biomarkers have not been or cannot be tested or a positive biomarker of neuronal injury in a situation in which Αβ biomarkers have not been or cannot be tested indicate an intermediate likelihood that the MCI syndrome is due to AD. Such subjects are believed to be well suited for the methods described herein

[0290] Negative biomarkers for both Αβ and neuronal injury suggest that the MCI syndrome is not due to AD. In such instances the subjects may not be well suited for the methods described herein.

[0291] There is evidence that magnetic resonance imaging can observe

deterioration, including progressive loss of gray matter in the brain, from mild cognitive impairment to full-blown Alzheimer disease (see, e.g., Whitwell et al, (2008) Neurology 70(7): 512-520). A technique known as PiB PET imaging is used to clearly show the sites and shapes of beta amyloid deposits in living subjects using a CI 1 tracer that binds selectively to such deposits (see, e.g., Jack et al, (2008) Brain 131 (Pt 3): 665-680).

[0292] In certain embodiments, MCI is typically diagnosed when there is 1)

Evidence of memory impairment; 2) Preservation of general cognitive and functional abilities; and 3) Absence of diagnosed dementia. [0293] In certain embodiments, MCI and stages of Alzheimer's disease can be identified/categorized, in part by Clinical Dementia Rating (CDR) scores. The CDR is a five point scale used to characterize six domains of cognitive and functional performance applicable to Alzheimer disease and related dementias: Memory, Orientation, Judgment & Problem Solving, Community Affairs, Home & Hobbies, and Personal Care. The information to make each rating is obtained through a semi-structured interview of the patient and a reliable informant or collateral source (e.g., family member). [0294] The CDR table provides descriptive anchors that guide the clinician in making appropriate ratings based on interview data and clinical judgment. In addition to ratings for each domain, an overall CDR score may be calculated through the use of an algorithm. This score is useful for characterizing and tracking a patient's level of impairment/dementia: 0 = Normal; 0.5 = Very Mild Dementia; 1 = Mild Dementia; 2 =

Moderate Dementia; and 3 = Severe Dementia. An illustrative CDR table is shown in Table 3.

Table 3. Illustrative clinical dementia rating (CDR) table.

usual level in these independently Appears well Appears too in job, activities at these enough to be ill to be shopping, activities taken to taken to volunteer, although may functions functions and social still be outside a outside a groups engaged in family home family

some; home.

appears

normal to

casual

inspection

Home and Life at Life at home, Mild bit Only simple No

Hobbies home, hobbies, and definite chores significant hobbies, and intellectual impairment preserved; function in intellectual interests of function at very home interests slightly home; more restricted

well impaired difficult interests,

maintained chores poorly

abandoned; maintained

more

complicated

hobbies and

interests

abandoned

Personal Fully capable of self-care Needs Requires Requires

Care prompting assistance in much help dressing, with hygiene, personal keeping of care;

personal frequent effects incontinence

[0295] A CDR rating of -0.5 or -0.5 to 1.0 is often considered clinically relevant

MCI. Higher CDR ratings can be indicative of progression into Alzheimer's disease.

[0296] In certain embodiments, use of the MEND program described herein is deemed effective when there is a reduction in the CSF of levels of one or more components selected from the group consisting of Tau, phospho-Tau (pTau), APPneo, soluble Αβ40, soluble Αβ42, and/or Αβ42/Αβ40 ratio, and/or when there is a reduction of the plaque load in the brain of the subject, and/or when there is a reduction in the rate of plaque formation in the brain of the subject, and/or when there is an improvement in the cognitive abilities of the subject, and/or when there is a perceived improvement in quality of life by the subject, and/or when there is a significant reduction in clinical dementia rating (CDR), and/or when the rate of increase in clinical dementia rating is slowed or stopped and/or when the progression from MCI to early stage AD is slowed or stopped. [0297] In certain embodiments the use of the MEND program in combination with a drug for the treatment of MCI, dementia, and/or Alzheimer's disease (e.g., memantine, donepezil, tropisetron, rivastigmine, tacrine, etc.) is deemed effective when there is a reduction in the CSF of levels of one or more components selected from the group consisting of Tau, phospho-Tau (pTau), APPneo, soluble Αβ40, soluble Αβ42, and/or Αβ42/Αβ40 ratio, and/or when there is a reduction of the plaque load in the brain of the subject, and/or when there is a reduction in the rate of plaque formation in the brain of the subject that is greater than or longer lasting than the reduction that would be obtained with the use of the drug alone, and/or when there is an improvement in the cognitive abilities of the subject that is greater than or longer lasting than would be obtained with the use of the drug alone, and/or when there is a perceived improvement in quality of life by the subject that is greater than or longer lasting than would be obtained with the use of the drug alone, and/or when there is a significant reduction in clinical dementia rating (CDR) that is greater than or longer lasting than would be obtained with the use of the drug alone, and/or when the rate of increase in clinical dementia rating is slowed more than would occur with the use of the drug alone, and/or when the progression from MCI to early stage AD is slowed more than would occur with the use of the drug alone.

[0298] In some embodiments, a diagnosis of MCI can be determined by considering the results of several clinical tests. For example, Grundman, et al, (2004) Arch Neurol 61 : 59-66, report that a diagnosis of MCI can be established with clinical efficiency using a simple memory test (paragraph recall) to establish an objective memory deficit, a measure of general cognition (Mini-Mental State Exam (MMSE), discussed in greater detail below) to exclude a broader cognitive decline beyond memory, and a structured clinical interview (CDR) with patients and caregivers to verify the patient's memory complaint and memory loss and to ensure that the patient was not demented. Patients with MCI perform, on average, less than 1 standard deviation (SD) below normal on nonmemory cognitive measures included in the battery. Tests of learning, attention, perceptual speed, category fluency, and executive function may be impaired in patients with MCI, but these are far less prominent than the memory deficit. In certain embodiments the use of the MEND program in combination with a drug for the treatment of MCI, dementia, and/or Alzheimer's disease {e.g., memantine, donepezil, tropisetron, rivastigmine, tacrine, etc.) is deemed effective when there is a better performance in these clinical tests than obtained when the subject is treated with the drug alone or where improved performance persists for a longer periods of time than it would persist with the use of the drug(s) alone. Alzheimer's Disease (AO).

[0299] In various embodiments, the MEND program, alone or in combination with various drugs for the treatment of mild cognitive impairment (MCI), dementia, and/or Alzheimer's disease, can be used for the treatment of Alzheimer's disease. In such instances the methods described herein are useful in preventing or slowing the onset of Alzheimer's disease (AD), in reducing the severity of AD when the subject has transitioned to clinical AD diagnosis, and/or in mitigating one or more symptoms of Alzheimer's disease.

[0300] In particular, where the Alzheimer's disease is early stage, the methods can reduce or eliminate one or more symptoms characteristic of AD and/or delay or prevent the progression from MCI to early or later stage Alzheimer's disease, and/or prevent or delay the progression from an early stage of Alzheimer's disease to a later stage of Alzheimer's disease.

[0301] Individuals presently suffering from Alzheimer's disease can be recognized from characteristic dementia, as well as the presence of risk factors described above. In addition, a number of diagnostic tests are available for identifying individuals who have AD. Individuals presently suffering from Alzheimer's disease can be recognized from characteristic dementia, as well as the presence of risk factors described above. In addition, a number of diagnostic tests are available for identifying individuals who have AD. These include measurement of CSF Tau, phospho-tau (pTau), sAPPa, sAPPp, Αβ40, Αβ42 levels and/or C terminally cleaved APP fragment (APPneo). Elevated Tau, pTau, sAPPp and/or APPneo, and/or decreased sAPPa, soluble Αβ40 and/or soluble Αβ42 levels, particularly in the context of a differential diagnosis, can signify the presence of AD.

[0302] In certain embodiments, subjects amenable to treatment may have

Alzheimer's disease. Individuals suffering from Alzheimer's disease can also be diagnosed by Alzheimer's disease and Related Disorders Association (ADRDA) criteria. The

NINCDS-ADRDA Alzheimer's criteria were proposed in 1984 by the National Institute of Neurological and Communicative Disorders and Stroke and the Alzheimer's Disease and Related Disorders Association (now known as the Alzheimer's Association) and are among the most used in the diagnosis of Alzheimer's disease (AD). McKhann, et al, (1984) Neurology 34(7): 939-944. According to these criteria, the presence of cognitive impairment and a suspected dementia syndrome should be confirmed by

neuropsychological testing for a clinical diagnosis of possible or probable AD. However, histopathologic confirmation (microscopic examination of brain tissue) is generally used for a dispositive diagnosis. The NINCDS-ADRDA Alzheimer's Criteria specify eight cognitive domains that may be impaired in AD: memory, language, perceptual skills, attention, constructive abilities, orientation, problem solving and functional abilities). These criteria have shown good reliability and validity. [0303] Baseline evaluations of patient function can made using classic psychometric measures, such as the Mini-Mental State Exam (MMSE) (Folstein et al, (1975) J.

Psychiatric Research 12 (3): 189-198), and the Alzheimer's Disease Assessment Scale (ADAS), which is a comprehensive scale for evaluating patients with Alzheimer's Disease status and function {see, e.g., Rosen, et al, (1984) Am. J. Psychiatr., 141 : 1356-1364). These psychometric scales provide a measure of progression of the Alzheimer's condition. Suitable qualitative life scales can also be used to monitor treatment. The extent of disease progression can be determined using a Mini -Mental State Exam (MMSE) (see, e.g., Folstein, et al, supra). Any score greater than or equal to 25 points (out of 30) is effectively normal (intact). Below this, scores can indicate severe (<9 points), moderate (10-20 points) or mild (21-24 points) Alzheimer's disease.

[0304] Alzheimer's disease can be broken down into various stages including: 1)

Moderate cognitive decline (mild or early-stage Alzheimer's disease), 2) Moderately severe cognitive decline (moderate or mid-stage Alzheimer's disease), 3) Severe cognitive decline (moderately severe or mid-stage Alzheimer's disease), and 4) Very severe cognitive decline (severe or late-stage Alzheimer's disease) as shown in Table 4.

Table 4. Illustrative stages of Alzheimer's disease.

Be unable during a medical interview to recall such important details as their current address, their telephone number, or the name of the college or high school from which they graduated.

Become confused about where they are or about the date, day of the week or season.

Have trouble with less challenging mental arithmetic; for example, counting backward from 40 by 4s or from 20 by 2s.

Need help choosing proper clothing for the season or the occasion.

Usually retain substantial knowledge about themselves and know their own name and the names of their spouse or children.

Usually require no assistance with eating or using the toilet.

Severe cognitive decline (Moderately severe or mid-stage Alzheimer's disease)

Memory difficulties continue to worsen, significant personality changes may emerge, and affected individuals need extensive help with daily activities. At this stage, individuals may:

Lose most awareness of recent experiences and events as well as of their surroundings.

Recollect their personal history imperfectly, although they generally recall their own name.

Occasionally forget the name of their spouse or primary caregiver but generally can distinguish familiar from unfamiliar faces.

Need help getting dressed properly; without supervision, may make such errors as putting pajamas over daytime clothes or shoes on wrong feet.

Experience disruption of their normal sleep/waking cycle.

Need help with handling details of toileting (flushing toilet, wiping and disposing of tissue properly).

Have increasing episodes of urinary or fecal incontinence.

Experience significant personality changes and behavioral symptoms, including suspiciousness and delusions (for example, believing that their caregiver is an impostor); hallucinations (seeing or hearing things that are not really there); or compulsive, repetitive behaviors such as hand-wringing or tissue shredding.

Tend to wander and become lost.

Very severe cognitive decline (Severe or late-stage Alzheimer's disease)

This is the final stage of the disease when individuals lose the ability to respond to their environment, the ability to speak, and, ultimately, the ability to control movement.

Frequently individuals lose their capacity for recognizable speech, although words or phrases may occasionally be uttered.

Individuals need help with eating and toileting and there is general incontinence.

Individuals lose the ability to walk without assistance, then the ability to sit without support, the ability to smile, and the ability to hold their head up.

Reflexes become abnormal and muscles grow rigid. Swallowing is impaired.

[0305] In certain embodiments, use of the MEND program described herein when used with subjects diagnosed with Alzheimer's disease is deemed effective when the there is a reduction in the CSF of levels of one or more components selected from the group consisting of Tau, phospho-Tau (pTau), APPneo, soluble Αβ40, soluble Αβ42, and/or and Αβ42/Αβ40 ratio, and/or when there is a reduction of the plaque load in the brain of the subject, and/or when there is a reduction in the rate of plaque formation in the brain of the subject, and/or when there is an improvement in the cognitive abilities of the subject, and/or when there is a perceived improvement in quality of life by the subject, and/or when there is a significant reduction in clinical dementia rating (CDR) of the subject, and/or when the rate of increase in clinical dementia rating is slowed or stopped and/or when the progression of AD is slowed or stopped (e.g., when the transition from one stage to another as listed in Table 4 is slowed or stopped).

[0306] In certain embodiments the use of the MEND program in combination with a drug for the treatment of MCI, dementia, and/or Alzheimer's disease (e.g., memantine, donepezil, tropisetron, rivastigmine, tacrine, etc.) when used with subjects diagnosed with Alzheimer's disease is deemed effective when the there is a reduction in the CSF of levels of one or more components selected from the group consisting of Tau, phospho-Tau (pTau), APPneo, soluble Αβ40, soluble Αβ42, and/or and Αβ42/Αβ40 ratio, and/or when there is a reduction of the plaque load in the brain of the subject, and/or when there is a reduction in the rate of plaque formation in the brain of the subject where, and/or when there is an improvement in the cognitive abilities of the subject that is greater than or longer lasting than the reduction that would be obtained with the use of the drug alone, and/or when there is a perceived improvement in quality of life by the subject that is greater than or longer lasting than the reduction that would be obtained with the use of the drug alone, and/or when there is a significant reduction in clinical dementia rating (CDR) of the subject that is greater than or longer lasting than the reduction that would be obtained with the use of the drug alone, and/or when the rate of increase in clinical dementia rating is slowed to a greater degree or for a longer time than would be obtained with the use of the drug alone and/or when the progression of AD is slowed to a greater degree or for a longer time or stopped (e.g., when the transition from one stage to another as listed in Table 4 is slowed or stopped) for a longer time than would be obtained with the use of the drug alone. [0307] In various embodiments, the effectiveness of treatment can be determined by comparing a baseline measure of a parameter of disease before administration of the MEND program alone or in combination with one or more drugs as described herein is commenced to the same parameter one or more time points after the program is initiated. One illustrative, but non-limiting, parameter that can be measured is a biomarker (e.g., a peptide oligomer) of APP processing. Such biomarkers include, but are not limited to increased levels of sAPPa, p3 (Αβ 17-42 or Αβ 17-40), βΑΡΡβ, soluble Αβ40, and/or soluble Αβ42 in the blood, plasma, serum, urine, mucous or cerebrospinal fluid (CSF). Detection of increased levels of sAPPa and/or p3, and decreased levels of βΑΡΡβ and/or APPneo is an indicator that the treatment is effective. Conversely, detection of decreased levels of sAPPa and/or p3, and/or increased levels of βΑΡΡβ, APPneo, Tau or phospho-Tau (pTau) is an indicator that the treatment is not effective.

[0308] Another parameter to determine effectiveness of treatment is the level of amyloid plaque deposits in the brain. Amyloid plaques can be determined using any method known in the art, e.g., as determined by CT, PET, PIB-PET and/or MRI.

[0309] In various embodiments, use of the MEND program, alone or in combination with a drug for the treatment of mild cognitive impairment (MCI), dementia, and/or Alzheimer's disease as described herein can result in a reduction in the rate of plaque formation, and even a retraction or reduction of plaque deposits in the brain. Effectiveness of treatment can also be determined by observing a stabilization and/or improvement of cognitive abilities of the subject. Cognitive abilities can be evaluated using any art- accepted method, including for example, Clinical Dementia Rating (CDR), the mini-mental state examination (MMSE) or Folstein test, evaluative criteria listed in the DSM-IV

(Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) or DSM-V, and the like.

[0310] In certain embodiments, the monitoring methods can entail determining a baseline value of a measurable biomarker or parameter (e.g., amyloid plaque load or cognitive abilities) in a subject before administering a dosage of the multi-component formulation and optionally one or more pharmaceuticals, and comparing this biomarker or parameter with a value for the same measurable biomarker or parameter after treatment.

[0311] In other methods, a control value (e.g., a mean and standard deviation) of the measurable biomarker or parameter is determined for a control population. In certain embodiments, the individuals in the control population have not received prior treatment and do not have AD, MCI, nor are at risk of developing AD or MCI. In such cases, if the value of the measurable biomarker or clinical parameter approaches the control value, then treatment is considered efficacious. In other embodiments, the individuals in the control population have not received prior treatment and have been diagnosed with AD or MCI. In such cases, if the value of the measurable biomarker or clinical parameter approaches the control value, then treatment is considered inefficacious.

[0312] In other methods, a subject who is not presently receiving treatment but has undergone a previous course of treatment is monitored for one or more of the biomarkers or clinical parameters to determine whether a resumption of treatment is required. The measured value of one or more of the biomarkers or clinical parameters in the subject can be compared with a value previously achieved in the subject after a previous course of treatment. Alternatively, the value measured in the subject can be compared with a control value (mean plus standard deviation/ ANOVA) determined in population of subjects after undergoing a course of treatment. Alternatively, the measured value in the subject can be compared with a control value in populations of prophylactically treated subjects who remain free of symptoms of disease, or populations of therapeutically treated subjects who show amelioration of disease characteristics. In such cases, if the value of the measurable biomarker or clinical parameter approaches the control value, then treatment is considered efficacious and need not be resumed. In all of these cases, a significant difference relative to the control level (e.g., more than a standard deviation) is an indicator that treatment should be resumed in the subject.

[0313] In various embodiments, the tissue sample for analysis is typically blood, plasma, serum, urine, mucous or cerebrospinal fluid from the subject. Kits.

[0314] In certain embodiments kits are provided for the practice of the methdos described herein. In certain embodiments the kits contain one or more nutritional/dietary supplement components of the Metabolic Enhancement for Neurodegeneration (MEND) program as described herein. In certain embodiments the kits can additionally comprise one or more drugs including, but not limited to drug(s) for the treatment of MCI, dementia, and/or Alzheimer's disease.

[0315] In certain embodiments the kits additionally contain instructional materials.

Such instructional materials can include instructions for treatment using the MEND program alone or in combination with a drug for the treatment of MCI, dementia, and/or Alzheimer's disease. Often and typically the instructional materials are provided in written form and can be printed on the kit components themselves (e.g. on the cover of a box, container, or on an envelope, or can be provided as an insert/instructional page or booklet. While the instructional materials typically comprise written or printed materials they are not limited to such. Any medium capable of storing such instructions and communicating them to an end user is contemplated by this invention. Such media include, but are not limited to electronic storage media (e.g., magnetic discs, tapes, cartridges, chips), optical media (e.g., CD ROM), and the like. Such media may include addresses to internet sites that provide such instructional materials.

EXAMPLES

[0316] The following examples are offered to illustrate, but not to limit the claimed invention.

Example 1

Case Studies

Patient One

Patient One: History

[0317] A 67-year-old woman presented with two years of progressive memory loss.

She held a demanding job that involved preparing analytical reports and traveling widely, but found herself no longer able to analyze data or prepare the reports, and therefore was forced to consider quitting her job. She noted that when she would read, by the time she reached the bottom of a page she would have to start at the top once again, since she was unable to remember the material she had just read. She was no longer able to remember numbers, and had to write down even 4-digit numbers to remember them. She also began to have trouble navigating on the road: even on familiar roads, she would become lost trying to figure out where to enter or exit the road. She also noticed that she would mix up the names of her pets, and forget where the light switches were in her home of years.

[0318] Her mother had developed similar progressive cognitive decline beginning in her early 60s, had become severely demented, entered a nursing home, and died at approximately 80 years of age. When the patient consulted her physician about her problems, she was told that she had the same problem her mother had had, and that there was nothing he could do about it. He wrote "memory problems" in her chart, and therefore the patient was turned down in her application for long-term care.

[0319] After being informed that she had the same problem as her mother had had, she recalled the many years of her mother' s decline in a nursing home. Knowing that there was still no effective treatment and subsequently losing the ability to purchase long-term care, she decided to commit suicide. She called a friend to commiserate, who suggested that she get on a plane and visit, and then referred her for evaluation.

[0320] She began System 1.0 (Table 5), and was able to adhere to some but not all of the protocol components. Nonetheless, after three months she noted that all of her symptoms had abated: she was able to navigate without problems, remember telephone numbers without difficulty, prepare reports and do all of her work without difficulty, read and retain information, and, overall, she became asymptomatic. She noted that her memory was now better than it had been in many years. On one occasion, she developed an acute viral illness, discontinued the program, and noticed a decline, which reversed when she reinstated the program. Two and one-half years later, now age 70, she remains

asymptomatic and continues to work full-time.

Patient one: therapeutic program

[0321] As noted above, and following an extended discussion of the components of the therapeutic program, the patient began on some but not all of the system: (1) she eliminated all simple carbohydrates, leading to a weight loss of 20 pounds; (2) she eliminated gluten and processed food from her diet, and increased vegetables, fruits, and non-farmed fish; (3) in order to reduce stress, she began yoga, and ultimately became a yoga instructor; (4) as a second measure to reduce the stress of her job, she began to meditate for 20 minutes twice per day; (5) she took melatonin 0.5mg po qhs; (6) she increased her sleep from 4-5 hours per night to 7-8 hours per night; (7) she took methylcobalamin lmg each day; (8) she took vitamin D3 2000IU each day; (9) she took fish oil 2000mg each day; (10) she took CoQio200mg each day; (11) she optimized her oral hygiene using an electric flosser and electric toothbrush; (12) following discussion with her primary care provider, she reinstated HRT (hormone replacement therapy) that had been discontinued following the WHI report in 2002; (13) she fasted for a minimum of 12 hours between dinner and breakfast, and for a minimum of three hours between dinner and bedtime; (14) she exercised for a minimum of 30 minutes, 4-6 days per week

Table 5. Therapeutic system 1.0.

1732; 50. Tag aatea et

pyr oxa - -p osp ate; , tr met y g yc ne; rp, tryptop an.

Patient two.

Patient two: history

[0322] A 69-year-old entrepreneur and professional man presented with 11 years of slowly progressive memory loss, which had accelerated over the past one or two years. In 2002, at the age of 58, he had been unable to recall the combination of the lock on his locker, and he felt that this was out of the ordinary for him. In 2003, he had FDG-PET (fluoro-deoxyglucose positron emission tomography), which was read as showing a pattern typical for early Alzheimer's disease, with reduced glucose utilization in the parietotemporal cortices bilaterally and left > right temporal lobes, but preserved utilization in the frontal lobes, occipital cortices, and basal ganglia. In 2003, 2007, and 2013, he had quantitative neuropsychological testing, which showed a reduction in CVLT (California Verbal Learning Test) from 84%ile to l%ile, a Stroop color test at 16%ile, and auditory delayed memory at 13%ile. In 2013, he was found to be heterozygous for ApoE4 (3/4). He noted that he had progressive difficulty recognizing the faces at work (prosopagnosia), and had to have his assistants prompt him with the daily schedule. He also recalled an event during which he was several chapters into a book before he finally realized that it was a book he had read previously. In addition, he lost an ability he had had for most of his life: the ability to add columns of numbers rapidly in his head. He had a homocysteine of 18 pmol/1, CRP <0.5mg/l, 25- OH cholecalciferol 28ng/ml, hemoglobin Ale 5.4%, serum zinc 78mcg/dl, serum copper 120mcg/dl, ceruloplasmin 25mg/dl, pregnenolone 6ng/dl, testosterone 610ng/dl, albumimglobulin ratio of 1.3, cholesterol 165mg/dl (on Lipitor), HDL 92, LDL 64, triglyceride 47, AM Cortisol 14mcg/dl, free T3 3.02pg/ml, free T4 1.27ng/l, TSH 0.58mIU/l, and BMI 24.9.

[0323] He began the therapeutic program, and after six months, his wife, coworkers, and he all noted improvement. He lost 10 pounds. He was able to recognize faces at work unlike before, was able to remember his daily schedule, and was able to function at work without difficulty. He was also noted to be quicker with his responses. His life-long ability to add columns of numbers rapidly in his head, which he had lost during his progressive cognitive decline, returned. His wife pointed out that, although he had clearly shown improvement, the more striking effect was that he had been accelerating in his decline over the prior year or two, and this had been completely halted.

Patient two: therapeutic program

[0324] The patient began on the following parts of the overall therapeutic system:

(1) he fasted for a minimum of three hours between dinner and bedtime, and for a minimum of 12 hours between dinner and breakfast; (2) he eliminated simple carbohydrates and processed foods from his diet; (3) he increased consumption of vegetables and fruits, and limited consumption of fish to non-farmed, and meat to occasional grass-fed beef or organic chicken; (4) he took probiotics; (5) he took coconut oil i tsp bid; (6) he exercised strenuously, swimming 3-4 times per week, cycling twice per week, and running once per week; (7) he took melatonin 0.5mg po qhs, and tried to sleep as close to 8 hours per night as his schedule would allow; (8) he took herbs Bacopa monniera 250mg, Ashwagandha 500mg, and turmeric 400mg each day; (9) he took methylcobalamin lmg, methyltetrahydrofolate 0.8mg, and pyridoxine-5- phosphate 50mg each day; (10) he took citicoline 500mg po bid; (11) he took vitamin C lg per day, vitamin D3 5000IU per day, vitamin E 400IU per day, CoQi ₀ 200mg per day, Zn picolinate 50mg per day, and a-lipoic acid lOOmg per day; (12) he took DHA (docosahexaenoic acid) 320mg and EPA

(eicosapentaenoic acid) 180mg per day.

Patient three

Patient three: history

[0325] A 55-year-old attorney suffered progressively severe memory loss for four years. She accidentally left the stove on when she left her home on multiple occasions, and then returned, horrified to see that she had left it on once again. She would forget meetings, and agree to multiple meetings at the same time. Because of an inability to remember anything after a delay, she would record conversations, and she carried an iPad on which she took copious notes (but then forgot the password to unlock her iPad). She had been trying to learn Spanish as part of her j ob, but was unable to remember virtually anything new. She was unable to perform her job, and she sat her children down to explain to them that they could no longer take advantage of her poor memory, that instead they must understand that her memory loss was a serious problem. Her children noted that she frequently became lost in mid-sentence, that she was slow with responses, and that she frequently asked if they had followed up on something she thought she had asked them to do, when in fact she had never asked them to do the tasks to which she referred. Her homocysteine was 9.8pmol/l, CRP 0.16mg/l, 25- OH cholecalciferol 46ng/ml, hemoglobin Ale 5.3%, pregnenolone 84ng/dl, DHEA 169ng/dl, estradiol 275pg/ml, progesterone 0.4ng/ml, insulin 2.7pIU/ml, AM Cortisol 16.3mcg/dl, free T3 3.02pg/ml, free T4 1.32ng/l, and TSH 2.04mIU/l.

[0326] After five months on the therapeutic program, she noted that she no longer needed her iPad for notes, and no longer needed to record conversations. She was able to work once again, was able to learn Spanish, and began to learn a new legal specialty. Her children noted that she no longer became lost in mid-sentence, no longer thought she had asked them to do something that she had not asked, and answered their questions with normal rapidity and memory. Patient three: therapeutic program

[0327] She began on the following parts of the therapeutic system: (1) she fasted for a minimum of three hours between dinner and bedtime, and for a minimum of 12 hours between dinner and breakfast; (2) she eliminated simple carbohydrates and processed foods from her diet; (3) she increased consumption of vegetables and fruits, limited consumption of fish to non-farmed, and did not eat meat; (4) she exercised 4-5 times per week; (5) she took melatonin 0.5mg po qhs, and tried to sleep as close to 8 hours per night as her schedule would allow; (6) she tried to reduce stress in her life with meditation and relaxation; (7) she took methylcobalamin lmg 4x/wk and pyridoxine-5-phosphate 20mg each day; (8) she took citicoline 200mg each day; (9) she took vitamin D3 2000IU per day and CoQ _J0 200mg per day; (10) she took DHA 700mg and EPA 500mg bid; (11) her primary care provider prescribed bioidentical estradiol with estriol (BIEST), and progesterone; (12) her primary care provider worked with her to reduce her bupropion from 150mg per day to 150mg 3x/wk.

Summary of patients.

[0328] All 10 patients are summarized in Table 6.

Table 6. Summary of patients treated with the therapeutic system described

methylene tetrahydrofolate reductase (MTHFR); FH, family history; aMCI, amnestic mild cognitive impairment; SCI, subjective cognitive impairment; FDG-PET+, fluorodeoxyglucose positron emission tomography interpreted as typical of Alzheimer's disease; amyloid PET+, amyloid PET scan read as abnormal, indicative of amyloid accumulation; Psych+, quantitative neuropsychology tests showing abnormalities typical of AD; MoCA, Montreal Cognitive Assessment; MemTrax, an iPhone

application that quantitates memory.

Discussion.

[0329] Results from the 10 patients reported here suggest that memory loss in patients with subjective cognitive impairment, mild cognitive impairment, and at least the early phase of Alzheimer's disease, may be reversed, and improvement sustained, with the therapeutic program described here. This is the first such demonstration.

[0330] The results reported here are compatible with the notion that metabolic status represents a crucial, and readily manipulable, determinant of plasticity, and in particular of the abnormal balance of plasticity exhibited in SCI, MCI, and early AD. Furthermore, whereas the normalization of a single metabolic parameter, such as vitamin D3, may exert only a modest effect on pathogenesis, the optimization of a comprehensive set of parameters, which together form a functional network, may have a much more significant effect on pathogenesis and thus on function.

[0331] The therapeutic system described in this example derives from basic studies of the role of APP signaling and proteolysis in plasticity, and the imbalance in this receptor proteolysis that reproducibly occurs in Alzheimer's disease. There are numerous physiological parameters that feed into this balance, such as hormones (Lan et al. (2015) J. Alzheimers Dis. 43(4): 1137-1148; Shi et al. (2014) J. Steroid Biochem. Mol. Biol. 144PB: 280-285), trophic factors (Lourenco et al. (2009) Cell Death Differ . 16: 655-663), glucose metabolism (Yang et al. (2013) PLoS One, 8: e69824), inflammatory mediators (Sutinen et al. (2012) J. Neuroinflammation, 9: 199), ApoE genetic status (Theendakara et al. (2013) Proc. Natl. Acad. Sci. USA, 110: 18303-18308) sleep-related factors (Wade et al. (2014) Clin. Interv. Aging, 9: 947-961), exercise-related factors (Cotman et al. (2007) Trends Neurosci. 30: 464-472), and many others; therefore, the therapeutic system is designed to reverse the self-reinforcing {i.e., prionic) signaling imbalance that we have hypothesized to mediate Alzheimer's disease pathophysiology (Bredesen (2009) Mol. Neurodegener, 4:27).

[0332] One potentially critical result from the study is the impact of the therapeutic program on the ability of the various patients to work effectively. Six of the 10 patients had had to discontinue working or were struggling with their jobs at the time of presentation, and all were able to return to work or continue working with improved performance. One additional patient had not had difficulty at work at the time of presentation, and has continued to work without difficulty. The other three patients had not worked for years, and did not begin again after treatment. The improvement in function that is required to work effectively after struggling due to cognitive decline is an important outcome of any successful therapeutic system, and is ultimately more critical to the patients than biomarker effects or test performance.

[0333] It is recognized that the system described here is an initial system, one that is likely to benefit from optimization. The system is designed to address multiple key pathogenetic mechanisms, but most of the key pathogenetic mechanisms are suboptimally affected by this initial system. This highlights multiple potential therapeutic targets, and optimizing the therapeutics for each of these targets is the goal of ongoing research and development.

[0334] It is noteworthy that the major side effect of this therapeutic system is improved health and optimal BMI (body mass index), a result in stark contrast to monopharmaceutical treatments. However, the program is not easy to follow, and none of the patients followed the entire protocol. The significant diet and lifestyle changes, and multiple pills required each day, were the two most common complaints of the patients. However, these complaints were mitigated by the fact that all of the patients had previously been made aware, either through their physicians or the media, that their prognosis was poor and their cognitive decline essentially untreatable.

[0335] One potentially important application of the therapeutic program described herein is that such a therapeutic system may be useful as a platform on which drugs that would fail as monotherapeutics may succeed as key components of a therapeutic system. Combination therapeutics have proven successful in multiple chronic illnesses, such as HIV and cancer (Bredesen and John 92013) EMBO Mol Med. 5: 795-798).

Conclusions:

[0336] A novel, comprehensive, and personalized therapeutic system is described that is based on the underlying pathogenesis of Alzheimer's disease. The basic tenets for the development of this system are also described. Of the first 10 patients who utilized this program, including patients with memory loss associated with Alzheimer's disease (AD), amnestic mild cognitive impairment (aMCI), or subjective cognitive impairment (SCI), nine showed subjective or objective improvement. One potentially important outcome is that all six of the patients whose cognitive decline had a major impact on job performance were able to return to work or continue working without difficulty.

Example 2

Reversal of cognitive decline in Alzheimer's disease

0337] A therapeutic approach for the treatment of Alzheimer's disease and its precursors (e.g., mild cognitive impairment (MCI)) is described herein. The therapeutic approach used was programmatic and personalized rather than monotherapeutic and invariant, and is dubbed metabolic enhancement for neurodegeneration (MEND). Patients who had had to discontinue work were able to return to work, and those struggling at work were able to improve their performance. The patients, their spouses, and their co-workers all reported clear improvements. Here we report the results from quantitative MRI and neuropsychological testing in ten patients with cognitive decline, nine ApoE4+ (five homozygous and four heterozygous) and one ApoE4-, who were treated with the MEND protocol for 5-24 months. The magnitude of the improvement is unprecedented, providing additional objective evidence that this programmatic approach to cognitive decline is highly effective. These results have far-reaching implications for the treatment of Alzheimer's disease, MCI, and SCI; for personalized programs that may enhance pharmaceutical efficacy; and for personal identification of ApoE genotype.

Introduction

[0338] Alzheimer' s disease is now the third leading cause of death in the United

States, following only cardio- vascular disease and cancer (James et al. (2014) Neurology. 82: 1045-1050). There are approximately 5.2 million Americans with AD, but this estimate ignores the many young Americans destined to develop AD during their lifetimes: given the lifetime risk of approximately 15% when including all ApoE genotypes, as many as 45 million of the 318 million Americans now living may develop AD during their lifetimes if no prevention is instituted (Seshadri et al. (1995) Arch Neurol. 52: 1074-1079).

[0339] Here we report the initial follow-up of ten patients who were treated with a novel programmatic approach involving metabolic enhancement. One patient had well documented mild cognitive impairment (MCI), with a strongly positive amyloid-PET (positron emission tomography) scan, positive FDG-PET scan (fluorodeoxyglucose PET scan), abnormal neuropsychological testing, and hippocampal volume reduced to 17th percentile; after 10 months on the MEND protocol, his hippocampal volume had increased to 75th percentile, in association with a reversal of cognitive decline. Another patient had well documented early Alzheimer's disease, with a positive FDG-PET scan and markedly abnormal neuro- psychological testing. After 22 months on the MEND protocol, he showed marked improvement in his neuropsychological testing, with some improvements reaching three standard deviations from his earlier testing.

[0340] The initial results for these patients show greater improvements than have been reported for other patients treated for Alzheimer's disease. The results provide further support for the suggestion that such a comprehensive approach to treat early Alzheimer's disease and its precursors, MCI and SCI, is effective. The results also support the need for a large-scale, personalized clinical trial using this protocol.

Results - Case Studies.

Patient 1.

[0341] A 66-year-old professional man presented with what he described as "senior moments" (for example, forgetting where his keys were or forgetting appointments) of two- years duration, and difficulty performing his work. There was a positive family history of dementia in both parents. He was an ApoE4 heterozygote (3/4), his amyloid PET scan was markedly positive, and his fluorodeoxyglucose (FDG) PET scan showed temporoparietal reduced glucose utilization indicative of Alzheimer's disease. An MRI showed

hippocampal volume at only 17th percentile for his age. His neuropsychological testing was compatible with a diagnosis of MCI. His hs-CRP was 9.9 mg/1, albumin: globulin ratio was 1.6, homocysteine 15.1 μπιοΐ/ΐ, fasting glucose 96 mg/dl, hemoglobin Ale 5.5%, fasting insulin 32 mIU/1, 25-hydroxychole-calciferol 21 ng/ml, TSH 2.21 mIU/1, and testosterone 264 ng/dl.

[0342] He began the MEND protocol, lost 18 pounds, and after three months his wife reported that his memory had improved. He noted that his work came more easily to him. However, after five months, he discontinued the majority of the program for approximately three weeks. His wife came home to find his car in the driveway, idling with the keys in the ignition, while he was inside the house, working and unaware that he had left the car idling in the driveway. He re-initiated the program, and had no further such episodes.

[0343] After 10 months on the program, he returned for a follow-up MRI, which was subjected to volumetric analyses by both Neuroquant (Ross et al. (2012) J. Neuropsychiatry Clin. Neurosci. 24: 1 : E33) and Neuroreader (Ahdidan et al. (2015) J. Alzheimer sDis. 49: 723-732) programs. The former indicated an increase in hippocampal volume from 17th percentile to 75th percentile, with an associated absolute increase in hippocampal volume of 11.7%. The Neuroreader program showed an absolute increase from 7.65cc to 8.3cc, which represents an 8.5% absolute increase in size. The associated Z- scores were -4.6 and +1.6, respectively, disclosing an increase from <5th percentile to the 90th percentile. Thus although the Neuroquant and Neuroreader analyses differed somewhat in the amplitude of the effect detected, they were in agreement that a relatively large magnitude increase in hippocampal volume had occurred. [0344] Follow-up metabolic analysis also disclosed improvement, with hs-CRP having decreased from 9.9mg/l to 3mg/l, fasting insulin having decreased from 32mIU/l to 8mIU/l, homocysteine having decreased from 15.1 μιηοΐ/ΐ to 8 μιηοΐ/ΐ, and 25- hydroxychole- calciferol having increased from 21 ng/ml to 40 ng/ml. See Table 7 for a summary of the responses of all patients to the treatment program. Table 7. Patient responses to the MEND treatment protocol.

neuropsychological testing

improvement

xSee text for details of treatment outcome.

Comment:

[0345] This patient had well documented Alzheimer's disease, with a strongly positive amyloid PET scan, characteristic FDG PET scan, abnormal neuropsychological studies, positive family history, ApoE4-positive (3/4) genotype, and hippocampal volume of 17th percentile. During his 10 months on the MEND protocol, he interrupted his otherwise good compliance once, and this was associated with an episode of memory loss, in which he failed to remember that he had left his car in the driveway while he was working in his house. He returned to the protocol at that time, and after 10 months in total, he

demonstrated not only a marked symptomatic improvement (which had begun after approximately three months on the protocol), but also a dramatic increase in hippocampal volume. More modest hippocampal volumetric increases have been described with exercise (Erickson et al. (2011) Proc. Natl. Acad. Sci. USA, 108: 3017-3022) and with a brain- training program (Fotuhi et al. (2016) J. Prev. Alz. Dis.Z/dx.doi. org/10.14283/jpad.2016.92), but to our knowledge the magnitude of hippocampal volume increase that occurred with this patient has not been reported previously.

Patient 2.

[0346] A 69-year-old entrepreneur and professional man presented with 11 years of slowly progressive memory loss, which had accelerated over the past one to two years. In 2002, at the age of 58, he had been unable to recall the combination of the lock on his locker, and he felt that this was out of the ordinary for him. In 2003, he had an FDG PET scan, which was read as showing a pattern typical for early Alzheimer's disease, with reduced glucose utilization in the parietotemporal cortices bilaterally and left > right temporal lobes, but preserved utilization in the frontal lobes, occipital cortices, and basal ganglia. In 2003, 2007, and 2013, he had quantitative neuropsychological testing, which showed a reduction in CVLT (California Verbal Learning Test), a Stroop color test at 16th percentile, and auditory delayed memory at 13th percentile. In 2013, he was found to be heterozygous for ApoE4 (3/4). He noted that he had progressive difficulty recognizing the faces at work (prosopagnosia), and had to have his assistants prompt him with the daily schedule. He also recalled an event during which he was several chapters into a book before he finally realized that it was a book he had read previously. In addition, he lost an ability he had had for most of his life: the ability to add columns of numbers rapidly in his head. [0347] He was advised that, given his status as an Alzheimer's disease patient and his clear progression, as well as his poor performance on the 2013 test, he should begin to "get his affairs in order." His business was in the process of being shut down due to his inability to continue work. [0348] His laboratory values included a homocysteine of 18 μιηοΐ/ΐ, CRP <0.5 mg/1,

25-hydroxycholecalciferol 28 ng/ml, hemoglobin Ale 5.4%, serum zinc 78 mcg/dl, serum copper 120 mcg/dl, coppenzinc ratio of 1.54, ceruloplasmin 25mg/dl, pregnenolone 6 ng/dl, testosterone 610 ng/dl, albumimglobulin ratio of 1.3, cholesterol 165 mg/dl (on

atorvastatin), HDL 92mg/dl, LDL 64 mg/dl, triglycerides 47 mg/dl, AM Cortisol 14 mcg/dl, free T3 3.02pg/ml, free T4 1.27ng/l, TSH 0.58mIU/l, and BMI 24.9.

[0349] He began on the MEND therapeutic program, and after six months, his wife, co-workers, and he all noted improvement. He lost 10 pounds. He was able to recognize faces at work unlike before, was able to remember his daily schedule, and was able to function at work without difficulty. He was also noted to be quicker with his responses. His life-long ability to add columns of numbers rapidly in his head, which he had lost during his progressive cognitive decline, returned. His wife pointed out that, although he had clearly shown improvement, the more striking effect was that he had been accelerating in his decline over the prior year or two, and this had been completely halted.

[0350] After 22 months on the program, he returned for follow- up quantitative neuropsychological testing, which revealed marked improvement: his CVLT-IIB had increased from 3rd percentile to 84th percentile (3 standard deviations), total recognized hits from <lst percentile to 50th percentile, CVLT-II from 54th percentile to 96th percentile, auditory delayed memory from 13th percentile to 79th percentile, reverse digit span from 24th percentile to 74th percentile, and processing speed from 93rd percentile to 98th percentile. His business, which had been in the process of termination, was reinvigorated, and a new site was added to the previous sites of operation.

Comment:

[0351] This patient had well-documented Alzheimer's disease, with an ApoE4- positive genotype, characteristic FDG-PET scan, characteristic abnormalities on

neuropsychological testing, well documented decline on longitudinal quantitative neuropsychological testing, and progression of symptoms. After two years on the protocol, his symptoms and neuropsychological testing improved markedly. The neuropsychologist who performed and evaluated his testing pointed out that his improvement was beyond that which had been observed in the neuropsychologist's 30 years of practice.

Patient 3.

[0352] A woman late in her fifth decade began to note episodes of forgetfulness, such as returning home from shopping without the items she had purchased.

[0353] She also placed household items in the wrong locations repeatedly, and frequently failed to recognize previously familiar faces. She had difficulty remembering which side of the road on which to drive. A male cousin had developed Alzheimer's disease in his fifth decade. She was found to be an ApoE4 homozygote. On-line cognitive evaluation showed her to be at the 35th percentile for her age, despite her having been an excellent student earlier in her life.

[0354] She began various parts of the MEND protocol, and slowly added protocol features over several months. She began to note improvement, and her on-line cognitive evaluation improved to the 98th percentile, where it has remained to the current time, with her having been on the protocol for 3.5 years.

Comment:

[0355] This patient showed early but definite cognitive decline, documented by online quantitative cognitive testing. Her marked improvement has now been sustained for 3.5 years. Patient 3's improvement was iterative, with continued optimization over several months.

Patient 4.

[0356] A 49-year-old woman noted progressive difficulty with word finding, and noted that her vocabulary had become more limited. She also began to feel unsure about her navigation during driving. She also complained of difficulty with facial recognition (prosopagnosia). Her recall was affected, and she described the requirement of "more energy" for recall of events. She had difficulty with remembering scheduled events. She also noted that her clarity and sharpness were reduced, leading to difficulties assisting her children with schoolwork. She had difficulty with complex conversations, and with reading comprehension. She also lost the ability she had had to speak two foreign languages. [0357] Her family history was positive for Alzheimer's disease in her father, and her

ApoE genotype was 2/4. Her MRI was read as normal, but volumetrics were not included. She underwent quantitative neuropsychological testing at a major university center, and was told that she was in the early stages of cognitive decline and therefore ineligible for the Alzheimer's prevention program, since she was already too late in the disease course for prevention. Her homocysteine was ΙΟμΜ, hs-CRP 0.6 mg/1, hemoglobin Ale 5.2%, fasting insulin 7 mIU/1, TSH 1.6 mIU/1, and 25-hydroxycholecalciferol 35 ng/ml.

[0358] She began on the MEND protocol, and over the next several months she noted a clear improvement in recall, reading, navigating, vocabulary, mental clarity, and facial recognition. Her foreign language abilities returned. Nine months after her initial neuro- psychological testing, the testing was repeated at the same university site, and she was told that she no longer showed evidence of cognitive decline. Immediate and delayed recall, as well as semantic knowledge, executive function, and processing speed, had all shown improvement.

Comment:

[0359] This patient had typical early amnestic MCI, which reverted over several months, resulting in a normal neuropsychological examination after nine months. She remains asymptomatic after one year on the program.

Patient 5.

[0360] A 55-year-old woman presented with memory concerns of two-years duration. She had a positive family history of dementia in an aunt and a grandmother. She was an ApoE4 homozygote and a TOMM40 homozygote (G/G).

[0361] She experienced difficulties with word recall several times a day, either being unable to recall the word at all or substituting the wrong word in its place. For example, she would say a word like "tweezers" when she meant to say "tongs" (semantic paraphasic errors). She also experienced an increase in spelling errors as she typed on her computer. As a professional writer and editor with a master's degree in English, she found these issues very troubling. She often lost her train of thought while speaking, requiring her to ask others what she had just said. In addition, she would misplace items and forget why she had walked into a room. She would also forget some things her husband had told her or asked her to do. [0362] She began the MEND protocol, and after four months her husband reported that her memory had improved. She noted that her word recall was as good as it had ever been, and she was no longer experiencing an increase in spelling errors. She also reported that she rarely lost her train of thought, but if she went off on a tangent or if someone interrupted her, that issue might return. However, if she paused and gave herself a few seconds, she could find her way back to her original train of thought without asking for help. In addition, she no longer forgot why she had entered a room, and only rarely misplaced items.

[0363] Her primary care provider noted that, in her professional opinion, her cognition had returned to normal after four months on the protocol, and an on-line cognitive test (CNS Vital Signs), performed prior to the start of the protocol and then again after five months on the protocol, confirmed this opinion: her overall cognitive assessment

(neurocognitive index) had increased from 16th percentile to 73rd percentile; composite memory from 1st percentile to 61st percentile; verbal memory from 3rd percentile to 93rd percentile; visual memory from 5th percentile to 14th percentile; executive function from 14th percentile to 58th percentile; and processing speed from 37th percentile to 81st percentile. Improvement had occurred in all sub- tests. Comment:

[0364] This patient is homozygous for ApoE4, and presented with amnestic MCI.

She showed a clear response, both subjectively and objectively, to the metabolic protocol, and has sustained improvement over seven months.

Patient 6.

[0365] A 74-year-old attorney presented with a five-year history of memory loss and word-finding difficulty. His family history was positive for dementia in his mother, beginning at the age of 75 years. He had been evaluated at an Alzheimer's disease center at the onset of his memory loss, and was found to be ApoE4/4, with MRI showing ventricular enlargement and temporal lobe atrophy, right > left, and FDG-PET showing reduced glucose utilization in the temporal lobes and the precuneus, compatible with Alzheimer's disease. Neuropsychological testing was compatible with a diagnosis of amnestic MCI. He was treated with donepezil, memantine, and intravenous immunoglobulin, and his MMSE fell from 27 to 23 over three years. He noted no improvement with the treatment.

[0366] He began the MEND protocol, and after six months, his MFI (phagocytosis index) was measured at 1260, with normal being >500 and most Alzheimer's patients scoring <500 (Fiala et al. (2005) J. Alzheimers Dis. 7: 221 -232; Masoumi et al. (2009) J. Alzheimer s Dis. 17: 703-717). His MMSE was 29. He returned three months later, his MMSE was 30, and his MFI was 1210. He then returned three months after that, complaining that he had taken a trip, gone off much of the protocol, come under stress, and he felt that his memory had declined. His MFI at that visit had dropped to 230, a typical score for a patient with Alzheimer's disease, and his MMSE was 28. He was placed back on the protocol, and returned two months later, with MFI of 1100 and MMSE of 30. Over the ensuing 12 months, his MFI remained >1000 and his MMSE remained at 30.

Comment:

[0367] This patient, homozygous for ApoE4/4, had a typical amnestic presentation and well documented Alzheimer's disease, unresponsive to donepezil, memantine, and intravenous immunoglobulin. His MMSE improved to a perfect 30 on the metabolic protocol, where it has remained for over one year. His longitudinal MFI supports the notion that MFI may provide a "real time" method for following inflammatory/metabolic status, given the marked reduction when off the protocol with return to normal when he re-initiated the protocol. Patient 7.

[0368] A 57-year-old man began to have difficulty with memory and in work performance as a computer programmer, leading to dismissal from his job. Over the next five years his cognition continued to decline, he developed navigational difficulties, had difficulty with attention and multi-tasking, and became quieter and less self-assured. He had been a superb guitarist, and he lost both the chord progression memory and the nuance in his playing. Family history was positive for dementia in his mother, in her ninth decade. Evaluation by a neurologist included an unremarkable brain MRI without volumetrics, and he was placed on Aricept, which he discontinued after two months.

[0369] Seven years after his symptom onset, he was again evaluated, and found to be homozygous for ApoE4. An FDG PET scan was strongly suggestive of Alzheimer's disease, with reductions in glucose utilization in the temporal, parietal, posterior cingulate, and frontal regions, with some asymmetry. He scored 22/30 on the mini-mental state examination, having lost points for failing to know the date or day, location, and failing tasks of attention and short-term recall. His BMI was 23. [0370] A diagnosis of Alzheimer's disease was made. His laboratory evaluation included an hs-CRP of 0.2mg/l, homocysteine 9.5 μπιοΐ/ΐ, albumimglobulin ratio of 1.6, hemoglobin Ale 5.7%, fasting insulin 4.9 mIU/1, free T3 2.8 pg/ml, free T4 1.3 ng/1, TSH 2.1 mIU/1, testosterone 281 ng/dl, pregnenolone 44 ng/dl, 25-hydroxychole- calciferol 38 ng/ml, total cholesterol 145 mg/dl (on atorvastatin), RBC magnesium 4.7 mg/dl, serum copper 93 mcg/dl, serum zinc 76 mcg/dl, coppenzinc ratio 1.22, and AM Cortisol 6.8 mcg/dl. His Cyrex Array 2 was positive for gastrointestinal hyperpermeability, Cyrex Array 3 (for gluten sensitivity) was negative, and Cyrex Array 20 (for blood-brain barrier disruption) was negative.

[0371] He was placed on the MEND protocol, and his MMSE increased to 26 after four months, and to 29 after 10 months. His wife noticed clear improvement in his memory and navigation. His guitar skills improved, both his chord progressions and the nuances of his playing, such that he was able to play several pieces for the neurologist.

Comment:

[0372] This patient had well documented Alzheimer's disease, with a characteristic presentation, characteristic FDG-PET scan, and an ApoE4 homozygous genotype. For the seven years prior to beginning the MEND protocol, his cognition declined, again in keeping with the diagnosis of Alzheimer's disease. Therefore, the chance that his MMSE improved from 22 to 26 and then to 29 over the 10 months on the protocol, as a random event unrelated to the MEND protocol, is slim. Although a score of 29 on the MMSE is within the normal range, both the patient and his wife recognize that subjectively he has not returned completely to normal, and continued optimization of his metabolic status is ongoing.

Patient 8.

[0373] A 68-year-old business executive presented with a five-year history of progressive memory loss, forcing him to retire from his company. He had difficulty navigating while driving, as well. Family history was positive in his mother. He underwent amyloid PET imaging, which was positive. His ApoE genotype was 3/4.

[0374] After six months on the MEND protocol, his BMI improved from 27.7 to

24.6, and his hemoglobin Ale improved from 5.9% to 5.7%. Both he and his family noted improvement in memory and navigation. His improvement was documented by on-line neuropsychological testing (Brain HQ), which showed increase from 0 (baseline) to 2221, which represented 52nd percentile for his age. Comment:

[0375] This patient had typical Alzheimer's disease with mnemonic and visuospatial deficits, progressive course, positive family history, ApoE4 heterozygosity, and a positive amyloid PET scan. He responded to treatment with an improvement in BMI, reduction in hemoglobin Ale, symptomatic improvements in both memory and navigation, and objective improvement in on-line neuropsychological testing.

Patient 9.

[0376] A 50-year-old woman developed depression following a hysterectomy. She received hormone replacement therapy, but the depression continued. At the age of 54, she began to have word-finding difficulty, disorientation, difficulty driving, difficulty following recipes and other instructions, and memory complaints, and these problems progressed. She became quieter and slower to respond. Her depression deepened when her son left home.

[0377] She underwent neuropsychological testing, which disclosed frontal, temporal, and parietal abnormalities. A PET scan was typical for Alzheimer's disease, with temporoparietal decreases in glucose utilization as well as a modest frontal decrease. She was placed on duloxetine, which reduced her depression, and donepezil, which improved her cognition. However, she continued to decline.

[0378] At the age of 57, she was again evaluated. Her ApoE genotype was 3/3,

MoCA was 19/30, BMI was 18, hs- CRP 0.2 mg/1, homocysteine 8 μΜ, fasting insulin 4.2 ulU/ml, hemoglobin Ale 5.1%, free T3 2.1 pg/ml, free T4 1.33 ng/dl, reverse T3 23 ng/dl, fT3 :rT3 9, TSH 1.16 ulU/ml, progesterone 0.3ng/ml, AM Cortisol 7.2 mcg/dl, pregnenolone 19 ng/dl, 25- hydroxycholecalciferol 37 ng/ml, vitamin B12 799 pg/ml, alpha-tocopherol 12.5 mg/1, zinc 82 mcg/1, copper 99 mcg/1, coppenzinc ratio 1.2, ceruloplasmin 20 mg/dl, total cholesterol 221 mg/dl, HDL cholesterol 67 mg/dl, non- HDL cholesterol 167 mg/dl, triglycerides 82 mg/dl, urinary mercury: creatinine < 2.8, Lyme antibodies negative, C4a 5547 ng/ml, TGF-βΙ 7037 pg/ml, and VEGF (vascular endothelial growth factor) 56 pg/ml (normal range 31-86 pg/ml). VIP (vasoactive intestinal peptide) was not evaluated. HLA- DR/DQ was 13-6-52A (mycotoxin sensitive) and 15-6-51 (Borrelia sensitive). MARCoNS (multiple- antibiotic-resistant coagulase-negative Staph) culture was negative. Anti- thyroglobulin antibodies were strongly positive at 2076 IU/ml (normal range 0-0.9 IU/ml) and anti-thyroid peroxidase antibodies positive at 58 IU/ml (normal range 0-34 IU/ml).

[0379] She was placed on the MEND protocol, and intranasal VIP (vasoactive intestinal peptide) was administered. After three months, she showed improvement. She was able to babysit her grandchildren. She was able to follow written and verbal instructions without any problems, which had not been possible prior to treatment. She was able to read and remember overnight, and discuss her reading with her husband, which she had not been able to do prior to treatment. She also routinely remembered events of the previous day, which had not occurred in the few years prior to treatment. She had a follow- up MoCA test, and scored 21/30.

Comment:

[0380] This patient had progressed beyond MCI to Alzheimer's disease, well documented by characteristic PET scan abnormalities, neuropsychological testing deficits, and progression. Despite an initial subjective response to donepezil, she continued to decline and displayed significant impairment. She was diagnosed with type 3 Alzheimer's disease (Bredesen (2015); Aging, 7: 595-600; Bredesen (2016) Aging, 8: 304-313), and laboratory data supported this diagnosis with characteristic HLA- DR/DQ and abnormal C4a and TGF-βΙ, as well as anti- thyroglobulin antibodies and anti-thyroid peroxidase antibodies, although MARCoNS culture was negative.

[0381] After three months of therapy, she showed clear subjective improvement and modest objective improvement. Her previous three years of relentless decline argued against the possibility that the improvement was random and unrelated to her treatment.

Patient 10.

[0382] A 54-year-old woman presented with a two-year history of memory loss.

She noted that she did not retain new information the way she formerly had, she had to reread information a number of times to remember it, especially technical or scientific information, and noted that her reading speed had decreased. She also noted a reduction in vocabulary, word-finding problems, and repeated use of the same word instead of using synonyms. She also noted increased difficulty with grammar and spelling, as well as loss of names of friends and of famous people. Her writing declined, her typographical errors increased, and she had difficulty remembering passwords. She had increasing difficulty driving, organizing, and with her motivation. Activities of daily living were preserved.

[0383] Her ApoE genotype was 4/4, homocysteine 7.5μπιο1/1, hs-CRPO.26 mg/1, albumimglobulin ratio 2.0, hemoglobin Ale 5.3%, fasting insulin 2.7 mIU/1, fasting glucose 81 mg/dl, alpha-tocopherol 18.3 mg/1, and 25- hydroxycholecalciferol 188ng/ml. [0384] On-line quantitative neuropsychological testing disclosed a composite memory score at the 32nd percentile, visual memory at 10th percentile, and verbal memory at 73rd percentile. This testing was repeated after four months on the protocol, at which time the composite memory score was at the 61st percentile, visual memory score at the 25th percentile, and verbal memory score at the 84th percentile.

Comment:

[0385] This person, who is homozygous for the ApoE ε4 allele, demonstrated both subjective and objective evidence of cognitive decline, with preserved activities of daily living, and thus would fit best with a diagnosis of mild cognitive impairment. After four months on the protocol, repeat on-line quantitative neuropsychological testing revealed improvements in visual and verbal memory. Although these improvements were relatively modest, they are in contrast to the natural history of progressive decline in cognition for MCI associated with ApoE4 homozygosity.

Discussion

[0386] These observations provide further support for the finding that the personalized protocol for metabolic enhancement (note that the metabolic evaluation included parameters shown to affect Alzheimer's disease pathophysiology, such as homocysteine (Hooshmand et al. (2010) Neurology 75: 1408-1414), glucose (Yang et or/. (2013) PLoS One, 8:69824), and inflammation (Calsolaro and Edison (2016) Dement. 12: 719-732), as well as numerous others (Bredesen (2014) Aging 6: 707-717) in Alzheimer's disease leads to the reversal of cognitive decline in at least some patients with early

Alzheimer's disease or its precursors, MCI (mild cognitive impairment) and SCI (subjective cognitive impairment). To our knowledge, the magnitude of the improvements documented in patients 1 and 2 is unequaled in previous reports: in patient 1, the increase in

hippocampal volume from 17th percentile to 75th percentile supports the marked symptomatic improvement that he (and others) achieved on the protocol. In patient 2, quantitative neuropsychological testing demonstrated improvements of up to three standard deviations (CVLT-IIB, from 3rd percentile to 84th percentile), with multiple tests all showing marked improvements. These findings complement and support the marked subjective improvement previously observed for this patient.

[0387] It is noteworthy that these patients met criteria for Alzheimer's disease or

MCI prior to treatment, but failed to meet criteria for either Alzheimer's disease or MCI following treatment— i.e., following treatment, most had returned to the normal range for their cognitive testing. Furthermore, discontinuation of the protocol was associated with cognitive decline (here, in patient 1). It is not yet known for how many months or years the marked improvements will be sustained, but loss of improvement in patients maintaining the protocol has not yet been observed, and follow-ups of up to four years have now occurred.

[0388] The hippocampal volumetric increase observed for patient 1 does not discriminate between the possibility that synaptic number increased, or glial cell number or volume increased, or endogenous stem cell survival increased, or neuronal cell number or volume increased, or the vascular compartment increased, or some combination of these possibilities. This volumetric increase, and the marked symptomatic improvement that accompanied it, raises the question of whether it is possible that the patient's diagnosis of mild cognitive impairment associated with Alzheimer's disease was incorrect. However, the diagnostic evaluation makes this possibility extremely unlikely: given the strong family history of dementia, the ApoE4 heterozygosity, markedly positive amyloid PET scan, the FDG-PET scan characteristic of Alzheimer's disease with reduced glucose utilization in a temporoparietal distribution, the abnormal neuropsychological testing, and the MRI showing hippocampal volume at 17th percentile for age, the possibility that the underlying pathological process was something other than Alzheimer's disease is remote. Thus it would be expected that hippocampal volume would decrease over time, and that cognitive decline would occur. Therefore, the likelihood that his improvement was random and unrelated to the intervention is extremely low.

[0389] Similarly, for patient 2, it is highly unlikely that the diagnosis of Alzheimer's disease was incorrect: the ApoE4-positive genotype, the FDG-PET scan typical of

Alzheimer's disease with temporoparietal reduction in glucose utilization, the pattern and severity of quantitative neuropsychological abnormalities, and the well documented progressive nature of the deficits all provide strong support for the diagnosis of Alzheimer's disease. Furthermore, the severity of the abnormalities documented by the quantitative neuropsychological assessment was also compatible with the diagnosis of Alzheimer's disease. The variations that may occur when different examiners perform the same set of quantitative neuropsychological tests is an obvious concern when there is a significant change in the results of the tests in one subject. However, in this case, the same examiner performed the same set of tests in each instance, arguing against the possibility that the major improvement observed was simply the result of examiner-related variability. The magnitude of the improvement also argued against this possibility. [0390] In each of these cases, obvious subjective improvement, noted by the patient, his/her significant other, and his/her co-workers, was accompanied by clear, quantitated, objective improvement. In the cases of patients 1 and 2, the improvement was of a magnitude not reported previously for patients with Alzheimer's disease. None of the 10 patients exhibited the cognitive decline that is characteristic of Alzheimer's disease, and the improvement experienced by all 10 has been sustained, with the longest time on the program being four years.

[0391] It has been claimed that there is nothing that will prevent, delay, or reverse

Alzheimer's disease (www.nih.gov/news-events/news - releases/independent- panel-finds- insufficient- evidence- support- preventive- measures-alzheimers-disease). Therefore, it is typically recommended that the ApoE genotype, which represents the most important genetic risk factor for Alzheimer's disease, not be evaluated in asymptomatic individuals, and many physicians do not evaluate ApoE genotype even in symptomatic patients.

However, the examples described here complement and extend our data and suggest that these claims are no longer valid. Thus, given the success of the therapeutic regimen used with these patients, it may be appropriate to evaluate the ApoE genotype as part of prevention and early reversal of symptoms. Given the approximately 75 million Americans who are heterozygous for the ApoE ε4 allele, and the approximately seven million

Americans who are homozygous, early identification and treatment (presymptomatic or symptomatic) could potentially have a major impact on the prevalence of Alzheimer's disease-mediated cognitive decline.

[0392] It is understood that the examples and embodiments described herein are for illustrative purposes only and that various modifications or changes in light thereof will be suggested to persons skilled in the art and are to be included within the spirit and purview of this application and scope of the appended claims. All publications, patents, and patent applications cited herein are hereby incorporated by reference in their entirety for all purposes.