Introduction
The intersection of Down syndrome (DS) and Alzheimer’s disease (AD) represents a unique and pressing challenge in clinical neurology. Due to the triplication of the amyloid precursor protein (APP) gene on chromosome 21, individuals with Down syndrome are genetically predisposed to the early development of AD pathology. Virtually all adults with DS exhibit amyloid-β (Aβ) plaques and tau tangles by age 40, yet the clinical manifestation of dementia varies significantly. For decades, clinicians have struggled with the diagnostic complexities of identifying cognitive decline against a background of intellectual disability. Recently, the focus has shifted toward plasma-based biomarkers as a scalable, cost-effective, and less invasive alternative to Positron Emission Tomography (PET) or cerebrospinal fluid (CSF) analysis. A landmark longitudinal study published in the Lancet Neurology by Janelidze et al. (2025) provides compelling evidence that plasma p-tau217 and glial fibrillary acidic protein (GFAP) are the most accurate predictors of disease progression in this high-risk population.
Highlights
The study provides several critical insights for the management of Alzheimer’s in Down syndrome:
- Plasma p-tau217 is the primary predictor of cognitive decline, progression to clinical dementia, and cerebral tau burden.
- Both plasma p-tau217 and GFAP serve as early indicators of amyloid-β accumulation in the brain.
- These biomarkers outperform traditional measures such as neurofilament light (NfL) and total tau (t-tau) in multivariate prognostic models.
- The findings support the integration of blood-based biomarkers into clinical trial designs for anti-amyloid and anti-tau therapies in the Down syndrome community.
Background: The Genetic Imperative
The pathophysiology of Alzheimer’s in Down syndrome is distinct but shares common pathways with sporadic and autosomal dominant AD. The overexpression of APP leads to an overproduction of Aβ peptides from birth. Consequently, the amyloid cascade begins decades earlier than in the general population. However, the transition from asymptomatic pathology to symptomatic dementia is not uniform. Until recently, tracking this progression required PET imaging—a method that is logistically challenging, expensive, and often distressing for individuals with intellectual disabilities. The development of high-sensitivity assays for plasma biomarkers like phosphorylated tau (p-tau), GFAP (a marker of astrogliosis), and NfL (a marker of axonal injury) offers a new frontier in monitoring these patients.
Study Design and Methodology
This longitudinal cohort study utilized data from the Alzheimer’s Biomarker Consortium-Down Syndrome (ABC-DS), involving seven university sites across the USA and UK. The researchers followed 258 adults with Down syndrome (aged 25 and older) prospectively, with assessments occurring approximately every 16 months.
Participants and Assessments
The cohort underwent rigorous baseline and longitudinal evaluations. The study measured several plasma biomarkers:
- p-tau217 (phosphorylated at threonine 217)
- Glial Fibrillary Acidic Protein (GFAP)
- Amyloid β 42/40 ratio (Aβ42/40)
- Neurofilament light (NfL)
- Total tau (t-tau)
Endpoints
The primary outcomes included changes in global cognitive function, measured by the Down Syndrome Mental Status Examination (DS-MSE), and changes in brain pathology as visualized by Aβ-PET and tau-PET imaging. Progression to a clinical diagnosis of dementia was also a key secondary endpoint, analyzed using Cox regression models to determine hazard ratios.
Key Findings: The Superiority of p-tau217
The results of the Janelidze et al. study delineate a clear hierarchy among plasma biomarkers. While several biomarkers showed univariate associations with AD progression, multivariate analysis revealed that p-tau217 is the most potent prognostic tool.
1. Predicting Cognitive Decline and Dementia
In combined models adjusting for other biomarkers, baseline p-tau217 was the only marker significantly associated with longitudinal changes in DS-MSE scores (β -0.30, p=0.0001). More importantly, p-tau217 was a powerful predictor of the transition to dementia, with a hazard ratio of 3.51 (95% CI 1.76–7.00, p=0.0004). This suggests that individuals with elevated baseline p-tau217 are more than three times as likely to progress to dementia over the follow-up period compared to those with lower levels.
2. Tracking Brain Pathology
The study established a strong correlation between plasma levels and neuroimaging findings. Baseline p-tau217 was significantly associated with longitudinal increases in tau-PET signal (0.42, p=0.0039). When examining amyloid accumulation, both p-tau217 (0.29, p=0.0003) and GFAP (0.37, p=0.0003) were robust predictors of Aβ-PET changes. This indicates that while p-tau217 is a general marker of the AD process, GFAP specifically reflects the neuroinflammatory response to early amyloid deposition in the DS brain.
3. Comparison with Other Biomarkers
Interestingly, while NfL and t-tau are often used as markers of neurodegeneration, they lost their independent predictive value for cognitive decline and PET changes when p-tau217 was included in the model. This highlights that p-tau217 is not just a marker of tau tangles, but a proxy for the entire amyloid-tau-neurodegeneration (ATN) framework in the context of Down syndrome.
Expert Commentary: Mechanistic Insights
The findings reinforce the biological plausibility of the amyloid-tau sequence. In Down syndrome, the chronic overproduction of Aβ likely triggers astrocytic activation (elevated GFAP) and subsequent tau phosphorylation (elevated p-tau217). The fact that p-tau217 predicts both tau-PET and cognitive decline suggests it is sensitive to the stage of the disease where tau begins to spread from the medial temporal lobe to the neocortex—the phase most closely linked to clinical symptoms.
From a clinical perspective, these biomarkers address a major unmet need. Standard cognitive tests can be confounded by varying levels of baseline intellectual disability. A biological readout provides an objective anchor for clinicians. However, it is important to note the study’s limitations: the PET imaging sub-cohort was smaller than the total sample, and the follow-up period, while longitudinal, captures only a segment of a decades-long disease process.
Conclusion and Clinical Implications
The study by Janelidze et al. marks a significant milestone in the field of Down syndrome-related Alzheimer’s disease. Plasma p-tau217 and GFAP provide a “molecular window” into the brain, allowing for the prediction of cognitive decline and pathological progression with high accuracy.
For clinical practice, these biomarkers could eventually be used to screen adults with DS, identifying those at highest risk for imminent dementia. In the realm of research, these findings are practice-changing. As anti-amyloid therapies (such as lecanemab or donanemab) are evaluated in the DS population, p-tau217 and GFAP will serve as essential pharmacodynamic markers to monitor treatment response and select appropriate participants for trials.
Funding and Clinical Trial Information
This study was supported by the European Research Council and the National Institute on Aging (National Institutes of Health). Data originated from the Alzheimer’s Biomarker Consortium-Down Syndrome (ABC-DS) study.
References
Janelidze S, Collij LE, Mattsson-Carlgren N, et al. Prediction of amyloid and tau brain deposition and cognitive decline in people with Down syndrome using plasma biomarkers: a longitudinal cohort study. Lancet Neurol. 2025 Jul;24(7):591-600. doi: 10.1016/S1474-4422(25)00158-9. PMID: 40541209.
