Push-pull hypothesis of Alzheimer's disease

The "push-pull" hypothesis of Alzheimer's disease (AD) emerges from a careful examination of the key discoveries over the past 40 years. Specifically, amyloid beta (Aβ) plays a direct role impairing endolysosome activity in neurons and microglia, promoting the collapse of proteostasis, reducing tau degradation, and facilitating the cell-to-cell transmission of aggregated tau. As neurons fail to maintain cell autonomous proteostasis, they transition to actively "pushing" tau pathology into interstitial spaces. This switch represents a rapidly progressing disease state, propagating misfolded tau to synaptically connected neurons. The "pull" hypothesis postulates the spatial distribution of amyloid in cortical regions facilitates the spread of spontaneously aggregating tau from the inferior temporal lobes, manifesting as the symptomology of cognitive decline. In microglia, the Aβ-induced endolysosomal impairment mimics a viral infection, eliciting a chronic and detrimental interferon-type inflammatory response. The push-pull framework makes key predictions about the future success of AD therapeutics.