Age-related cognitive decline and depressive symptoms are prevalent in later life, yet the genetic determinants of vulnerability remain unclear. Here, we investigated how genetic and epigenetic regulation of the serotonin transporter gene SLC6A4 contributes to susceptibility to these age-related conditions in later life. In community-dwelling older adults in Japan (N = 1,317), functional stratification of the serotonin transporter-linked polymorphic region (5-HTTLPR) revealed that participants with low-activity genotypes showed a robust co-occurrence of cognitive decline and depressive symptoms, whereas this comorbid pattern was not observed in those with the high-activity genotype. The genotype-dependent co-occurrence was consistently replicated across seven independent population-based cohorts (total N = 7,889). DNA methylation at a functional promoter CpG site increased with age and partially mediated age-related cognitive decline specifically among low-activity genotypes. In contrast, the high-activity genotype was associated with relative resistance to these functional declines, partly mediated by a protective effect on hippocampal volume during aging. Notably, genotype-dependent effects on hippocampal volume were absent in adolescence, indicating that the influence of SLC6A4 emerges in an aging-specific manner. Together, these findings identify SLC6A4 promoter activity as a key genetic factor modulating vulnerability and resilience in later life.
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