Distinct biological property of tau in tau‐first cognitive proteinopathy: Evidence by longitudinal clinical neuroimaging profiles and compared with late‐onset Alzheimer disease

Background Tau‐first cognitive proteinopathy (TCP) denotes a clinical phenotype of Alzheimer disease (AD) showing Florzolotau(18F) positron emission tomography (PET) positivity but a negative amyloid status. Aim We explored the biological property of tau using longitudinal cognitive and neuroimaging data in TCP and compared with late‐onset AD (LOAD). Method We enrolled 56 patients with LOAD, 34 patients with TCP, and 26 cognitive unimpaired controls. All of the participants had historical data of 2 to 4 three‐dimensional T1 images and 2 to 6 annual cognitive evaluations over a follow‐up period of 7 years. Tau topography was measured using Florzolotau(18F) PET. In the LOAD and TCP groups, we constructed tau or gray matter clusters covarying with the cognitive measurements. We used mediator analysis to explore the regional tau load as predictor, gray matter partitions as mediators, and significant cognitive test scores as outcomes. Longitudinal cognitive decline and cortical thickness degeneration pattern were analyzed using a linear mixed‐effects model. Results The TCP group had longitudinal declines in nonexecutive domains. The deterministic factor predicting the short‐term memory score in TCP was the hippocampal volume and not directly via the medial and lateral temporal tau load. These features formed the conceptual differences with LOAD. Discussion The biological properties of tau and the longitudinal cognitive‐imaging trajectory support the conceptual distinction between TCP and LOAD. TCP represents one specific entity featuring salient short‐term memory impairment, declines in nonexecutive domains, a slower gray matter degenerative pattern, and a restricted impact of tau.