Dissociable structural and molecular pathways of age-related variability in sustained attention

Sustained attention, the capacity to maintain goal-directed attention over extended periods, declines with age but with substantial individual variability across cognitively unimpaired (CU) older adults. We sought to determine the contributions of microstructural deterioration of the superior longitudinal fasciculus (SLF), the principal white-matter tract coupling prefrontal and parietal nodes of the dorsal attention network, as well as markers of preclinical Alzheimer’s disease (AD) to individual differences in sustained attention in ageing.

In 162 CU older adults (mean (SD) age = 73.0 (4.9), %F = 64.8) drawn from two Stanford ageing cohorts, we measured sustained attention using the gradual-onset Continuous Performance Task (gradCPT). Performance was indexed by a composite score (Att-Z) derived from discriminability (d′) and response-time variability (RTV). We used diffusion MRI tractography to quantify SLF fractional anisotropy (FA) and mean diffusivity (MD) alongside two control tracts, the corticospinal tract (CST) and cingulum (CGC). NULISA multiplex plasma immunoassays were used to measured AD-related pathology (pTau-181, pTau-217), neuroaxonal injury (NfL), and astrocytic reactivity (GFAP; plasma subsample N = 146). Parallel mediation and commonality analyses tested whether structural and plasma biomarker pathways contribute independently to individual differences in sustained attention function.

Older age was associated with lower Att-Z (β = −0.315, p < 0.001). In simultaneous three-tract regression models, only SLF microstructure uniquely predicted Att-Z (FA: β = +0.275, p < 0.001; MD: β = −0.320, p < 0.001). SLF microstructure mediated the age-attention relationship (FA indirect β _{unstandardised} = –0.01, p _boot <0.01, MD indirect β _{unstandardised} = –0.009 to –0.01, p _boot <0.05). Plasma pTau-181 (β = −0.212, p _FDR < 0.03), pTau-217 (β = −0.163, p _FDR < 0.05), and NfL (β = −0.156, p _FDR < 0.05) were negatively associated with Att-Z and each mediated effects of age on performance (pTau-181 indirect β _{unstandardised} = −0.008, p _boot < 0.01; pTau-217 indirect β _{unstandardised} = −0.006, p _boot < 0.05; NfL indirect β _{unstandardised} = −0.011, p _boot < 0.05), whereas GFAP showed no association with sustained attention in any model. SLF microstructure was negatively associated with age (FA β = −0.207, p < 0.01; MD β = +0.270, p < 0.001) but was not significantly associated with plasma biomarkers (all p > 0.10). In parallel mediation models, SLF microstructure and plasma pTau exhibited significant independent indirect effects on Att-Z (SLF FA indirect β _{unstandardised} = −0.010, p _boot < 0.01; SLF MD indirect β _{unstandardised} = −0.009 to −0.010, p _boot < 0.05; pTau-181 indirect β _{unstandardised} = −0.008 to −0.009, p _boot < 0.01; pTau-217 indirect β _{unstandardised} = −0.006 to −0.007, p _boot < 0.05). Effects of NfL were attenuated when combined in a model with pTau (indirect β _{unstandardised} = −0.005 to −0.008, p _boot > 0.15), suggesting shared variance among these markers.

These findings reveal multiple pathways that contribute to individual differences in sustained attention in ageing that are detectable before clinical impairment, including SLF white matter integrity –– which is linked to the structural disconnection of the dorsal attention network –– and preclinical AD pathology. The independence of these pathways identifies two separable biological targets for preserving attentional capacity in CU older adults.