Sex Moderates the Impact of Diagnosis and Amyloid PET Positivity on Hippocampal Subfield Volume

INTRODUCTION

Sex differences have been established in prevalence and rates of decline in Alzheimer’s disease (AD) [1–8], and a growing body of literature shows that sex differences also exist in early resilience to the neural burden of AD. Specifically, researchers have shown that women’s established verbal memory advantage over men [9–12] functions as a form of sex-specific cognitive reserve, affording women equal or better memory performances when compared to men despite positive neuroimaging biomarkers for AD, including mild to moderate levels of hippocampal atrophy [9], hypometabolism on fluorodeoxyglucose (FDG) positive emission tomography (PET) [10], and brain amyloid burden as measured by a positive florbetapir PET (A+) [11, 12].

Beyond cognitive reserve, recent research by our group suggests women may have neural reserve in the face of early AD pathology as indicated by biomarkers. Specifically, we have demonstrated that women— and not men— with A+ and normal cognition (NC) show right hippocampal volumes comparable to women with NC and a negative florbetapir PET study (A–); however, this sex-specific advantage is lost in early mild cognitive impairment (eMCI) [12]. Mechanisms of this proposed sex-based hippocampal reserve remain unclear, but may include a complex host of interactive factors including lifetime neuroprotective effects of estrogen [13, 14], and sex differences in genetic [5, 15], inflammatory [16], metabolic [17], and psychosocial factors [18].

Given the known route of progression of AD pathology through the hippocampus [19], researchers have emphasized the potential importance of examining hippocampal subfield volumes (SV). In particular, Cornu Ammonis 1 (CA1) and subiculum show pathology related to AD first, and changes in these regions also predict conversion to symptomatic AD [20–25]. In addition, subiculum changes have been correlated with cortical amyloid burden [26], and CA1 changes have been linked to memory encoding and retrieval deficits [20, 26–28]. Recent comprehensive reviews show CA1 as most consistently implicated in AD, and CA1 and subiculum in eMCI and individuals at risk for AD; however, findings are not fully consistent across methodologies, and other regions, including CA2, 3, 4, and dentate gyrus, have also been implicated in early disease [29].

The current study extends our previous work with whole hippocampal volumes [12]. In addition to replicating prior whole hippocampus findings with advanced segmentation technology and methods for controlling confounding factors [30–32], we examined whether sex and diagnosis moderate the effects of A+ on hippocampal SV. Specifically, we hypothesized that NC women with A+ would show CA1 and subiculum volumes comparable to NC women with A−. Although the literature has shown more tenuous support for AD-related changes in CA3, CA4, and dentate gyrus, such findings are nonetheless present, and as such we hypothesized that NC women with A+ would also show volumes in these regions comparable to NC women with A−. We hypothesized that this sex-based hippocampal subfield advantage would be lost in eMCI, with A+ effects being detrimental across sexes.

MATERIALS AND METHODS

RESULTS

Sex moderation of diagnosis and amyloid status effects on hippocampal total and subfield volume

Total hippocampal volume

In a replication of prior work with new techniques, the model with A+, diagnosis, sex, and their interactions predicting left HV was significant, F(11, 505) = 17.80; p < 0.001; R² = 0.29, yet the three-way interaction of A+, diagnosis, and sex was not significant, t(505) = −1.09, p = 0.27, indicating no moderating effects of sex and diagnosis on A+ effects for the left HV. Also replicating prior results, the model with A+, diagnosis, sex, and their interactions predicting right HV was significant, F(11, 505) = 18.10; p < 0.001; R² = 0.28, and the three-way interaction of A+, diagnosis, and sex was also significant, showing sex moderated the effects of diagnosis and A+ on right HV, t(505) = −2.02, p = 0.04. Parsing this interactive effect indicated that there were differences in the interactive effects of sex and amyloid status on right hippocampus volume in NC t(505) = 1.95, p = 0.05, but not eMCI t(505) = −0.77, p = 0.44. Specifically, there was no relationship of A+ to HV in NC women t(505) = −0.15, p = 0.88, but A+ related to smaller right HV in NC men t(505) = −2.44, p = 0.02. At the eMCI stage, A+ appeared to have a detrimental effect on right HV regardless of sex (men: t(505) = −1.64, p = 0.10; women t(505) = −2.78, p = 0.01). See Table 2 and Figs. 1A and 2A.

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Table 2

Summary of regression moderation analyses for left and right hippocampus and right subfield volume outcomes (N = 520)

Variable	Left Hippocampus
	B	p	95% Confidence Interval
Amyloid PET Positivity (A+)	−105.474	0.002	−171.956	−38.992
Diagnosis	−128.397	0.0001	−190.539	−66.256
Sex	−62.661	0.043	−123.325	−1.997
A+×Diagnosis×Sex	−131.935	0.275	−369.027	105.157
A+×Diagnosis	−53.209	0.377	−171.326	64.907
A+×Sex	54.453	0.358	−61.896	170.802
Diagnosis×Sex	−47.715	0.43	−166.427	70.998
Age	−22.373	<0.0001	−27.119	−17.626
Education	2.159	0.717	−9.514	13.833
Modified MoCA	32.95	<0.0001	18.655	47.244
APOE4 Carrier Status	−5.234	0.883	−74.798	64.33
Variable	Right Hippocampus
	B	p	95% Confidence Interval
Amyloid PET Positivity (A+)	−125.602	0.001	−200.745	−50.46
Diagnosis	−119.442	0.001	−191.152	−47.732
Sex	−70.393	0.049	−140.513	−0.272
A+×Diagnosis×Sex	−279.86	0.044	−552.656	−7.065
A+×Diagnosis	−14.367	0.837	−151.412	122.678
A+×Sex	76.974	0.266	−58.725	212.674
Diagnosis×Sex	−115.019	0.101	−252.623	22.586
Age	−22.702	<0.0001	−27.659	−17.746
Education	−6.647	0.288	−18.926	5.633
Modified MoCA	31.886	0.0001	15.846	47.927
APOE4 Carrier Status	−33.041	0.375	−106.172	40.089
Variable	Right Subiculum
	B	p	95% Confidence Interval
Amyloid PET Positivity (A+)	−16.199	0.003	−26.948	−5.45
Diagnosis	−17.937	0.0006	−28.162	−7.713
Sex	−9.603	0.054	−19.379	0.173
A+×Diagnosis×Sex	−42.895	0.033	−82.367	−3.423
A+×Diagnosis	−1.78	0.86	−21.549	17.989
A+×Sex	16.042	0.105	−3.388	35.471
Diagnosis×Sex	−11.939	0.238	−31.799	7.921
Age	−2.853	<0.0001	−3.579	−2.128
Education	−0.963	0.314	−2.839	0.913
Modified MoCA	3.972	0.0009	1.638	6.306
APOE4 Carrier Status	−9.156	0.093	−19.85	1.538
Variable	Right CA1
	B	p	95% Confidence Interval
Amyloid PET Positivity (A+)	−18.657	0.025	−34.958	−2.356
Diagnosis	−22.802	0.005	−38.743	−6.86
Sex	−21.379	0.007	−36.94	−5.818
A+×Diagnosis×Sex	−55.788	0.067	−115.54	3.967
A+×Diagnosis	−15.027	0.329	−45.257	15.202
A+×Sex	14.284	0.348	−15.597	44.166
Diagnosis×Sex	−33.353	0.03	−63.448	−3.258
Age	−3.265	<0.0001	−4.279	−2.251
Education	−0.948	0.48	−3.584	1.688
Modified MoCA	5.098	0.003	1.769	8.426
APOE4 Carrier Status	−6.82	0.384	−22.198	8.559
Variable	Right GC/ML/DG
	B	p	95% Confidence Interval
Amyloid PET Positivity (A+)	−11.867	0.001	−19.087	−4.648
Diagnosis	−5.17	0.142	−12.07	1.731
Sex	−9.548	0.006	−16.275	−2.821
A+×Diagnosis×Sex	−22.562	0.089	−48.611	3.49
A+×Diagnosis	−1.127	0.865	−14.168	11.914
A+×Sex	1.188	0.858	−11.836	14.212
Diagnosis×Sex	−10.969	0.101	−24.072	2.134
Age	−1.671	<0.0001	−2.139	−1.203
Education	−0.679	0.259	−1.859	0.502
Modified MoCA	3.699	<0.0001	2.086	5.311
APOE4 Carrier Status	0.04	0.991	−6.979	7.06
Variable	Right CA3
	B	p	95% Confidence Interval
Amyloid PET Positivity (A+)	−8.18	0.015	−14.75	−1.61
Diagnosis	−3.026	0.326	−9.075	3.023
Sex	−7.11	0.018	−13.014	−1.206
A+×Diagnosis×Sex	−13.056	0.265	−36.04	9.928
A+×Diagnosis	−2.195	0.706	−13.603	9.213
A+×Sex	−2.07	0.722	−13.51	9.369
Diagnosis×Sex	−9.438	0.108	−20.95	2.075
Age	−0.707	0.0006	−1.11	−0.303
Education	−0.07	0.898	−1.141	1.001
Modified MoCA	2.842	0.0001	1.461	4.223
APOE4 Carrier Status	3.786	0.246	−2.619	10.191
Variable	Right CA4
	B	p	95% Confidence Interval
Amyloid PET Positivity (A+)	−9.573	0.003	−15.783	−3.364
Diagnosis	−3.596	0.225	−9.412	2.22
Sex	−7.726	0.008	−13.46	−1.992
A+×Diagnosis×Sex	−20.095	0.075	−42.246	2.057
A+×Diagnosis	−0.594	0.916	−11.615	10.428
A+×Sex	1.228	0.827	−9.834	12.29
Diagnosis×Sex	−10.412	0.067	−21.534	0.71
Age	−1.189	<0.0001	−1.588	−0.789
Education	−0.55	0.28	−1.549	0.449
Modified MoCA	2.918	<0.0001	1.548	4.289
APOE4 Carrier Status	0.845	0.782	−5.149	6.839

Note: Age, education, and modified MoCA scores were centered at their means. Dichotomous variables were centered around zero. PET, positron emission tomography; A+, positive amyloid PET scan; MoCA, Montreal Cognitive Assessment; APOE, apolipoprotein E; CA, cornu ammonis; GC, granule cell layer; ML, molecular layer; DG, dentate gyrus. Left Hippocampus model R = 0.539, p < 0.0001. Right Hippocampus model R = 0.525, p < 0.0001. Right subiculum model R = 0.481, p < 0.0001. Right CA1 model R = 0.440, p < 0.0001. Right GC/ML/DG model R = 0.472, p < 0.0001. Right CA3 model R = 0.347, p < 0.0001. Right CA4 model R = 0.433, p < 0.0001.

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Fig. 1

Sex moderation of diagnosis and amyloid status effects. Sex moderates effects of diagnosis and Florbetapir PET amyloid positivity (A+) on right whole hippocampal volume (A), and right subiculum (B). Specifically, normal control (NC) women with A+ show whole and subfield volumes more comparable to NC women with a negative amyloid PET (A−), while NC men do not. At the early mild cognitive impairment (eMCI) stage, effects of A+ on total and subfield volume did not differ by sex, but generally related to smaller volumes across participants. A–, ¹⁸F-PET amyloid negative; A+, ¹⁸F-PET amyloid positive. For ease of viewing, hippocampus and subfield volume units are raw, uncorrected, in milimeters³.

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Fig. 2

Alternate presentation of sex moderation of diagnosis and amyloid status effects (breakdown by amyloid status). Sex moderates effects of diagnosis and Florbetapir PET amyloid positivity (A+) on right whole hippocampal volume (A), and right subiculum (B). Specifically, normal control (NC) women with A+ show whole and subfield volumes more comparable to NC women with a negative amyloid PET (A−), while NC men do not. At the early mild cognitive impairment (eMCI) stage, effects of A+ on total and subfield volume did not differ by sex, but generally related to smaller volumes across participants. Although not directly tested in this analysis, as shown, this figure also suggests that for A+ individuals, receiving an eMCI diagnosis is related to smaller volumes, specifically in women. A–, ¹⁸F-PET amyloid negative; A+, ¹⁸F-PET amyloid positive. For ease of viewing, hippocampus and subfield volume units are raw, uncorrected, in milimeters³.

Subfield volume

Following the significant right HV analysis, right hippocampal SV analyses showed the model for right subiculum was significant, F(11, 505) = 13.44; p < 0.001; R² = 0.23, and the sex by diagnosis by amyloid status interaction was also significant, t(505) = −2.14, p = 0.03. Parsing the interaction showed sex differences in the effect of A+ on subiculum volume in NC participants t(505) = 2.38, p = 0.02. Specifically, there was no relationship of A+ to subiculum volume in NC women t(505) = 0.35, p = 0.73, but A+ related to smaller subiculum volumes in NC men t(505) = −2.67, p = 0.01. Similar to findings for the whole right hippocampus, the interaction of sex and amyloid status was not significant in eMCI t(505) = −0.44, p = 0.66, but rather suggested that A+ is linked to smaller subiculum volumes in eMCI regardless of sex (men: t(505) = −1.64, p = 0.10; women: t(505) = −2.17, p = 0.03). See Table 2 and Figs. 1B and 2B.

While regression models were significant for the remaining SV (p < 0.001), sex by diagnosis by amyloid status interaction effects for these subfields were either at trend-level (right CA1, t(505) = −1.83, p = 0.07; right CA4, t(505) = −1.78, p = 0.08; right dentate gyrus, t(505) = −1.70, p = 0.09) or not significant (right CA3, t(505) = −1.12, p = 0.27). Within subfields showing trend-level three-way interactions, the pattern of findings was similar to the effect pattern for the subiculum (i.e., trends toward greater impact of A+ on SV in NC men than NC women, and general detrimental effects of A+ in eMCI across sexes). See Table 2.

DISCUSSION

The current study examined whether sex and diagnosis moderate impact of amyloid positivity on hippocampal subfield volume. We hypothesized NC women with A+ would show hippocampal subfield volumes comparable to those in NC women with A– in right CA1, subiculum, CA3, CA4, and dentate gyrus, implying resistance to early impact of disease, but that A+ status would be associated with smaller right SV across sexes in eMCI. This prediction was partially supported; sex and diagnosis significantly moderated amyloid and diagnosis effects on right subiculum, and trends were observed for right CA1, CA4, and dentate gyrus. Specifically, NC men with A+ showed significantly smaller subiculum volume than their A– counterparts, while this effect was not seen in NC women. At the eMCI stage, A+ was associated with smaller subiculum volume regardless of sex. Trend level results for the CA1, CA4, and dentate gyrus followed a similar pattern (i.e., NC men with A+ showed SV that were smaller than NC men with A–, but this effect was not observed in NC women; individuals with eMCI and A+ showed smaller SV than individuals with eMCI and A–, regardless of sex). Effects were observed while accounting for effects of baseline cognitive status, age, education, APOE4 carrier status, and total brain volume.

The present findings suggest women have neural reserve at the level of the subiculum, a hippocampal subfield impacted very early in the progression of AD pathology. Specifically, we demonstrated that subiculum volume in women appears to resist effects of, or be maintained despite presence of, A+ at the NC stage. In other words, women with NC, but high likelihood of developing AD (i.e., A+), have subiculum volumes that are consistent with those of healthy women. On the other hand, men with NC and increased likelihood for AD (i.e., A+) show smaller subiculum volumes than healthy men, even before impairments are noted on formal memory measures. Combined with recent research supporting memory reserve for women with fewer prodromal AD traits [9–12], the present results suggest that examining memory and hippocampal volume may more sensitively identify men than women at risk for future decline, though recent research additionally suggests that looking at changes in hippocampal volume over time may assist with prediction of AD in women [53]. This has important implications for both clinical decision making and selection and outcome measures in clinical trials.

The mechanism for sex effects on rates of hippocampal atrophy remains unclear and is an area for future study. One avenue to consider is that while estrogen loss at menopause and certain hormone therapy approaches have been examined as a risk factor for cognitive decline (for a review, see [54]), it has been more difficult to consider the earlier protective effects of estrogen and how those may play out, or interact with sexually dimorphic inflammatory [16] and metabolic factors [17]. In addition, much recent research has suggested the importance of both creating higher-level risk categories combining across biomarkers and controlling for comorbid risks, such as APOE4 carrier status, [15] age [55, 56], education, and lifestyle factors (e.g., exercise, smoking, and alcohol use). As many of these factors differ by sex, the present results emphasize that sex should be considered in these types of analyses. Recent research also suggests that examining the hippocampus from an anterior-to-posterior perspective combined with anatomical labeling may yield additional information [57].

Strengths of the present study include a relatively large, well-characterized study sample, use of the latest hippocampal segmentation technology [30], and rigorous control of potential confound variables according to recent field recommendations [15, 56]. At the same time, all methods of segmentation are vulnerable to errors, particularly with single anatomical images without very high resolution (i.e., greater than 3T as employed here). Future studies should replicate these findings with multiple images and at higher field strength, and with complementary methods for examining hippocampal structure, such as shape and radial distance analyses. In addition, the ADNI sample includes highly educated individuals with a restricted range of education; replication in other, more representative samples will be important. It also will be essential to examine sex differences in AD biomarkers longitudinally, to facilitate understanding of when exactly— or how much— pathology leads to cognitive, atrophic, and clinical symptom expression. Moreover, while the current investigation found significant three-way interactions representing an important preliminary finding, replication in larger samples will be necessary to ascertain that effects observed here are stable, truly sex-specific, and lateralized outside of the present sample, as well as to explore whether other subfields might reach significance. Additional investigation of the effects of estrogen levels and hormone replacement therapy will also be important in the future.

In sum, the present study provides additional evidence that in the face of AD, women have early neural reserve at the level of the hippocampus, and subiculum in particular. Findings were seen in a large sample, with the latest segmentation technology, and field-standard methods for controlling for potential confounds. If replicated in other samples and with other methods, early reserve for women in memory and hippocampal integrity could suggest need for changes in how and when women are screened for early signs of AD and how their progress is measured in clinical trials.