Today, I review, link to, and excerpt from “Suggestions for the decision making in subjective cognitive complaints”. [PubMed Abstract] [Full-Text HTML] [Full-Text PDF]. Aging Clin Exp Res. 2025 Jan 21;37(1):27. doi: 10.1007/s40520-024-02875-8.
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- Abstract
- Introduction
- Critical factors analysis in the management of subjective cognitive disorder
- Conclusions
- Author contributions
- Funding
- Declarations
- Footnotes
- References
Abstract
In recent years, the increasing life expectancy has underscored the importance of cognitive health alongside physical well-being, particularly because healthy adults may report subjective cognitive complaints (SCC), often related to memory. These complaints may or may not align with objective cognitive impairments, fueling ongoing debates about whether SCC could serve as an early indicator of dementia. While some studies suggest SCC as a potential precursor to dementia, others propose that these complaints may merely co-occur with cognitive decline. Despite the lack of consensus, addressing SCC remains crucial for early intervention, especially as emerging treatments for dementia show promise when applied at early stages. Risk factors associated with dementia, such as age, education, family history, and comorbid conditions like depression and diabetes, have been incorporated into predictive models. However, clinical practice continues to rely heavily on neuropsychological assessments to bridge subjective complaints with objective cognitive performance and may often require additional investigations, such as neuroimaging. Factors such as cognitive reserve, depression, stress, sleep disturbances, and personality traits also play significant roles in the interpretation of SCC. Some of these conditions may potentially mask underlying cognitive decline. A comprehensive clinical evaluation, integrating neuropsychological testing with a thorough anamnesis, can help distinguish between cognitive disorders and other contributing factors. Here, we propose a flowchart to guide clinicians in the management of SCC, integrating key factors to enhance diagnostic accuracy and inform treatment decisions. Despite the challenges involved, a careful and holistic approach remains essential for effective patient care.
Keyword: Subjective Cognitive Complaints (SCC), Dementia, Anamnesis, Neuropsychological Assessment, Risk Factors Introduction
A major debate in the scientific literature centers on whether SCC can be considered as an early indicator of dementia’s prodrome. Mendonca’s [1] systematic review highlights the risk of cognitive impairment in individuals with SCC, emphasizing a link between self-recognition of cognitive inefficiency and a significantly elevated risk of progressing to dementia. Recently, network analysis has been used to explore the relationship between SCC and normal versus pathological aging [2], suggesting that SCC might represent an intermediate stage between normal aging and mild cognitive impairment. However, these findings are not universally accepted. Some longitudinal studies report that individuals with more initial subjective memory complaints did not experience a faster decline in objective cognitive performance, suggesting that subjective cognitive impairments may not predict cognitive decline but rather co-occur with it [3].
A comprehensive neuropsychological examination is a critical initial step for determining the need for further investigation. It aligns the patient’s self-reported experiences with objective data, highlighting deviations from expected performance norms. When objective performance deficits emerge during these assessments, further investigations, including brain scans to rule out other neurological causes and to further assess brain functioning, are generally recommended.
However, beyond neuropsychological test outcomes, other factors may influence cognitive performance and subjective experiences of individuals with SCC. A comprehensive anamnesis, accounting for all factors influencing the individual’s perception of cognitive inefficiency, is essential. Informed decision-making, such as whether to prescribe additional tests or simply monitor the profile, relies on integrating neuropsychological assessment results with clinical and behavioral data.
In a recent predictive model by Anatürk and colleagues [6], factors forecasting dementia development over 14 years were identified: advanced age, lower educational attainment, diabetes, depression, stroke history, family history of dementia, socioeconomic disadvantage, hypertension, cholesterol status, male gender, and household occupancy. By studying a large sample of individuals, the authors developed a very useful program to calculate an individual’s dementia risk and classify healthy subjects into low-risk and high-risk groups. Nevertheless, the management of patients with SCC remains complex and challenging.
For example, how should clinicians interpret a clinical scenario where significant subjective cognitive disturbances are not matched by poor performance on neuropsychological tests? Can the absence of abnormalities in cognitive screening alone justify discontinuing ongoing monitoring of the cognitive profile? What specific anamnesis data can help clinicians consider alternative diagnoses beyond cognitive deterioration?
The Comprehensive Geriatric Assessment [7] is a valuable tool for supporting the diagnostic process. This multidimensional and multidisciplinary assessment focuses on elderly patients and encompasses three dimensions: physical performance, functional ability, and cognition and mental health. Additionally, Devita and collaborators [8] recently emphasized the importance of including a measure of cognitive reserve (CR) when suspecting cognitive impairment. CR refers to the accumulation of stimulating experiences throughout an individual’s life, including education, work, and recreational activities. Evidence shows that CR may act as a protective factor against neurodegenerative diseases (e.g., Stern et al., [9]). Interestingly, a high level of CR might initially mask objective cognitive deterioration. In individuals with high CR, cognitive decline may remain ‘silent’ due to the greater availability of neurological substrates and redundant networks in the brain. Therefore, subjective cognitive disturbances should be considered with greater caution in these cases, as individuals may become aware of inefficiencies before they are overtly apparent. Interesting, patients with high CR are also more likely to report inefficiencies compared to those with lower cognitive reserve, due to their greater awareness and perceived sense of self-efficacy. As a result, individuals with high CR require vigilant monitoring.
Nonetheless, CR is not the only factor to consider when addressing SCC. In 2013 [10], Mark and colleagues sought to standardize guidelines for evaluating SCC, identifying specific “red flags” that warrant further investigation in patients who report subjective cognitive deficits but show no abnormalities on brief cognitive screening. They highlight certain anamnesis elements that merit attention, such as high education and socioeconomic status, distinct complaints, marital status, age under 80, decline in instrumental activities of daily living, adequate effort on neuropsychological tests, and concurrent risk factors like depression, vascular or neurological diseases, or a slow gait. The authors recommend conducting a comprehensive neuropsychological evaluation and considering neuroimaging studies and biomarker assessments when most of these conditions are present. [Emphasis Added] This “Perspective” aims to prompt further reflection on the aspects to investigate when dealing with a subject exhibiting SCC. We will first outline the aspects to consider and then present a potential flowchart to aid in understanding the manifestation of SCC. Critical factors analysis in the management of subjective cognitive disorder
Depression and Stress. Existing literature highlights a significant association between subjective memory disturbances and depressive symptoms, particularly among older individuals. The cognitive decline associated with mood disorders is sometimes referred to as ‘depressive pseudodementia’. According to the DSM-V, individuals with major depression often report impaired cognitive abilities, difficulty concentrating, making minor decisions, and performing cognitively demanding tasks. When the depressive episode is effectively treated, the associated memory problems generally resolve. It is noteworthy that distinguishing between the symptoms of organic dementia and those stemming from a depressive state can be difficult, as they frequently coexist and influence each other.
Perceived stress is also considered a potential predictor of SCC. During the medical history interview, it is crucial to inquire about stressful life events such as illness, the loss of a loved one, or financial issues. In summary, a thorough clinical interview, potentially supplemented by a depression and anxiety screening questionnaire, is strongly recommended for evaluating SCC.
Personality. [Personality Traits] Research on personality traits has identified links between neuroticism and pronounced conscientiousness with SCC. Individuals with rigid and highly conscientious personalities may be more likely to perceive cognitive changes as pathological, as they may struggle to accept normal age-related cognitive changes. While comprehensive personality assessments through specific tests may not always be practical, a clinical interview can provide valuable insights into the individual’s personality profile.
Sleep Quality. Chronic sleep disturbances can negatively impact cognitive function, and evidence suggests a higher likelihood of subjective memory decline in middle-aged and older adults with insomnia disorders. Assessing sleep quality is an essential aspect of evaluating SCC.
