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What Does “Normal For Age” Really Mean?
Am I OK?
#1: As Always, Talk to Your Doctor
#2: Take “The Test”
“The Test”, commonly, is either the Mini Mental Status Exam (MMSE) or the Montreal Cognitive Assessment (MoCA). Both are quick, in-office “screening tests” for evaluating cognitive functions (see APPENDIX). Commonly used in primary care to identify those needing more detailed and definitive testing, such screening is required at the Medicare Annual Wellness Visit.
The MMSE, developed in 19751, is the more extensively used tool in both clinical and research settings for evaluating mental status. (NOTE: Any inferences or conclusions that I offer apply equally to the MoCA.) The MMSE has 30 questions and takes 5 to 10 minutes. Scores range from 0 to 30. (Normal: 24–30; Mild cognitive impairment: 18–23; Severe impairment: 0–17) Results are influenced by education level, cultural background, and language. These screening tests are not considered sufficient for a conclusive diagnosis of dementia and should be followed by more comprehensive assessments if impairment is detected. Such formal neurocognitive testing is administering by a specialist and can take the better part of a day.
#3: Interpret Your Score (This can be tricky)
MMSE PASS/FAIL IS GRADED ON A CURVE, and
THE CURVE IS AGE AND EDUCATION:
From K-12 to beyond, cognitive tests have assessed your performance in comparison with your peers, rather than against a fixed pass/fail standard (like a requirement to achieve a fixed percentage of correct answers to pass, like the written driver’s test).
One’s score is most accurate and fair when compared with results from those of similar age and educational background. “Normal” is defined by the results of the group to which you belong. The “Normal Range” is the 68% of scores falling in the middle of the bell-shaped distribution of your group’s results (See figure above) “Normal” MMSE scores are typically 24 – 30 (out of 30). Our absolute scores tend to decline with increasing age, with higher levels of education yielding higher average scores. For instance, individuals with at least nine years of schooling had a median score of 29, those with five to eight years scored 26, and those with zero to four years scored 22. One’s comparison group is a subset of one of seven age groups and four education levels.2 It’s not simple: Older adults or those with less formal education may score slightly lower on the MMSE even if they’re unimpaired. A 30-year-old with a college degree might be expected to score a perfect 30/30. A 78-year-old with a 6th-grade education might still be considered “normal” with a score of 22–24.
#4: “Failing” score? Go back to #1
#5: Q: “Normal” score! Am I Good to Go?
A: No, Not Really!
Even For Those of Us With a “Normal” Mental Status Exam, There Are Still Two Possible Diagnoses with Wildly Different Predicted Outcomes
#1. Age Related Cognitive Decline (ARCD)
(THIS is the label we want. ARCD is what is understood as normal cognitive aging.)
Characteristics of ARCD/Normal Aging:
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There is a normal and expected decline in one’s cognition due to aging, with gradual onset in mid-to-late adulthood
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Mild or no deficits on neuropsychological tests
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Minimal associated worry
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No specific biomarkers for Alzheimer’s disease (AD)
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Brain imaging shows normal age-related changes only (cortical thinning)
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😊Low risk for progression to dementia😊
#2. Subjective Cognitive Decline (SCD)
(Also called “Subjective Cognitive Impairment” – SCI)
SCD describes a more concerning group of memory-challenged seniors. Just like those with ARCD they also score within the normal range on cognitive tests. However, SCD is considered to be THE EARLIEST STAGE OF ALZHEIMER’S DISEASE. Defined in 2014 by a group of international researchers and clinicians3,4, SCD is the “Self-Reported experience of worsening or more frequent confusion or memory loss within the previous 12 months.”5
SCD has two primary characteristics: (1) Observation of decline by others is not required. Any worsening in memory or progressive confusion is from the individual’s perspective and unrelated to an acute event. (2) Performance on standardized cognitive tests remains normal.6
Unlike ARCD, SCD confers a considerable risk of future dementia. In an analysis of over 30 studies, individuals with SCD were more than twice as likely to develop dementia when compared to those without subjective concerns.7
Characteristics of Subjective Cognitive Decline (SCD):
Self-perceived decline in cognition, often without objective impairment
Often sudden or noticed by the individual earlier
Typically with normal test results, but subjective concern is present
Often associated with anxiety or worries about cognitive health
Can be associated with the presence of blood biomarkers of Alzheimer’s disease (AD) like amyloid deposition or the APOE ε4 gene
Brain Imaging may show findings consistent with AD
☹️Elevated risk for progression to Mild Cognitive Impairment and AD☹️
How Does One Distinguish Between These Two Conditionswith the Same “Normal” Test Results?
When One (SCD) is Twice as Likely to Lead to Alzheimer’s Disease?
You can ask yourself the “SCD Question”:
In this age of artificial intelligence, 12th generation scanners and uber-diagnostic micromolecules, it turns out that the conclusive test separating normal aging from an increased chance of Alzheimer’s disease is the answer to a simple question:
HOW DO YOU FEEL ABOUT YOUR MEMORY AND COGNITION?
(Thus, the label: “Subjective” Cognitive Decline)
SCD-PLUS clinical features include:
Subjective decline in memory, regardless of function in other cognitive domains
Onset within the past five years
Onset at age sixty or older (Those younger than sixty are more likely to have other or potentially reversible causes of SCD, like depression.)
“Concerns/Worry” (Those who worry significantly along with their perceived decline are at increased risk of objective decline or dementia in the future.)
Persistence of SCD longer than six months
Seeking medical help because of SCD
Confirmation of cognitive decline by an observer
In the absence of alternative explanations or positive neurocognitive testing, the presence of SCD-plus criteria both confirms the diagnosis of SCD and increases the possibility of having positive AD biomarkers.8
So, What Do Doctors and Dementia Researchers Have to Say About SCD?
How About the “Scientific Literature”?
Overall, SCD gets little love or attention from the dementia “community”. Many of the latest research efforts are directed towards recruiting subjects with normal cognitive testing (like those with SCD). How one feels about their memory is not part of the selection process. Researchers then use biomarkers to divide subjects for study into those with Preclinical Alzheimer’s disease (with a positive marker for eventual Alzheimer’s disease, but no cognitive defects) and those with negative markers. Biomarker-positive cognitively-unimpaired volunteers are ideal for long-term studies of early treatment interventions or dementia-prevention strategies. With increased recruitment for their high research value has come serious concerns about proper informed consent for biomarker testing of asymptomatic individuals. (See https://ouragingbrains.com/a-suicidal-reader-seeks-advice/)
With the recent introduction of anti-amyloid therapies and new easy biomarkers, is the research community losing interest in the very real distress so many experience from our day-to-day subjective concerns? Biomarkers can resolve all that messy, subjective self-definition ambiguity. In leaving the subjective behind, do they leave us behind, focused less on the person, and more on the molecule?
The idea that academic interest in those of us hoping to remain “Normal for Age” is waning seems reinforced by a search for key phrases in the titles of publications cited by the National Library of Medicine up to mid-May 2025.
“Normal for age” (i.e., Age Related Cognitive Decline – ARCD): a total of 300 citations since 1987
“Subjective Cognitive Decline”: 952 publications since 2014
“Alzheimer’s disease”: 79,653 total citations
A Lack of Bureaucratic Recognition Hampers the Study of Our Subjective Concerns:
SCD is not listed in the World Health Organization’s International Classification of Diseases (ICD), which assigns numeric codes to specific diagnoses. Nor can it be found in the American Psychiatric Association Manual of Mental Disorders, which only recognizes dementias as classes and subclasses of “Major Neurocognitive Disorder”. Diagnosis codes are the way that researchers and agencies track statistics like hospitalizations, disease frequency, outcomes, and billing. Because it is not recognized, coded, and recorded as a searchable diagnosis, seniors with SCD are harder to find and study via the usual means (medical, hospital, and insurance records and databases), severely limiting collection of comprehensive data.
What We Do Know About SCD Is Not Encouraging.
Even with that relative lack of attention, new research continues to show a significant relationship between SCD and the development of dementia. Over 10 years, 19.8% of SCD subjects aged 60–80 progressed to cognitive deterioration such as all-cause dementia and Alzheimer’s disease.9 Of 1622 dementia-free older adults in a national study, the presence of SCI was associated with a twofold increased dementia risk over 8 years.10 Endorsement of multiple SCD-plus features was associated with AD biomarkers in cognitively unimpaired older adults, “supporting their value as early behavioral markers of preclinical AD.”11,12
A QUESTION THAT I ASK MYSELF FREQUENTLY:
If You’re Worried, Why Not Just Take the Alzheimer’s Blood Test And KNOW?
Before you do so, I would advise that you read:
https://ouragingbrains.com/a-suicidal-reader-seeks-advice/
and
https://ouragingbrains.com/im-worried-about-alzheimers-should-i-undergo-biomarker-testing/ :
If I had to make just one cautionary point about the newly available “definitive” Alzheimer’s biomarker testing, it would be:
Our Doctors Cannot Verify This Diagnosis
The minute our test scores tank we move (up? , down?) to the diagnosis of Mild Cognitive Impairment (MCI). Our lower scores identifying MCI mean that we are demonstrating more memory or thinking problems than others the same age, but still without significant interference with daily life or independent function. Unlike SCD, MCI is recognized by the International Classification of Diseases (ICD) and comes with its own official ICD-10 code of G31.84.
In our doctors’ eyes, our subjective concerns identify us as just one more of the estimated 4-5% of primary care patients labeled as the “Worried Well”.14 Polite medical references to this condition use the phrase “Health Anxiety”. Public health journals and other sources have used the more disparaging category of “health anxiety/hypochondriasis resulting in increased healthcare service utilisation and disability as consequences.”15
Unlike SCD, even we belittled “Worried Well” qualify for official recognition and an ICD-10 code: “z71.1 – Person with a Feared Complaint in Whom No Diagnosis Is Made”. Those who “ask the question” and identify themselves as SCD can expect no other diagnosis and no action other than “See me in a year”, until their doctors can see, hear, or measure something tangible that tells them you are at risk for more. It takes an abnormal score on neurocognitive testing to get you an “?upgrade?” to a diagnosis of Mild Cognitive Impairment (MCI). At least partly due to having an ICD-10 code, which allows data collection across populations, we know that MCI is worse: with progression to Alzheimer’s disease at approximately 10–15% per year, and up to 50% progressing over 5 years.16
The Bottom Line
I offer no medical advice, only informed opinion, with references.
If your neurocognitive testing is normal, YOU are the only one who can say that you are not. Only you can diagnose your SCD.
“There’s no cure for Alzheimer’s, but there are treatments that may change disease progression and drug and non-drug options that may help treat symptoms.” https://www.alz.org/help-support/caregiving/daily-care/treatments (Alzheimer’sAccociation, Accessed June7, 2025)
APPENDIX
Cognitive Functions are:
Memory, attention, language, visuospatial skills (to mentally map and navigate our environment), executive functions (planning, organizing, decision-making), and orientation (who you are, where you are, and the time and date)
The MMSE: asses the following cognitive domains and related tasks (with the noted maximum score for each, Total = 30)
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Orientation: Asks about time (date, day, month, year, season) and place (country, city, hospital, etc.) (10)
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Registration: Name 3 unrelated objects and ask the person to repeat them (3)
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Attention and Calculation: Subtract 7 from 100 repeatedly or spell “WORLD” backwards (5)
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Recall: Ask for 3 objects named earlier (3)
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Language: Naming objects, repeating phrases, following a 3-step command, reading, writing a sentence, and copying a design (interlocking pentagons) (9)
REFERENCES
Folstein MF, Folstein SE, McHugh PR. (1975). “Mini-Mental State”: A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12(3):189–198. DOI: 10.1016/0022-3956(75)90026-6
Crum RM, Anthony JC, Bassett SS, Folstein MF. Population-based norms for the Mini-Mental State Examination by age and educational level. JAMA. 1993 May 12;269(18):2386-91. PMID: 8479064.
Jessen F, Amariglio RE, van Boxtel M, et al. A conceptual framework for research on subjective cognitive decline in preclinical Alzheimer’s disease. Alzheimers Dement. Nov 2014;10(6):844-52. doi:10.1016/j.jalz.2014.01.001.
Jessen F, Amariglio RE, Buckley RF, et al. The characterisation of subjective cognitive decline. Lancet Neurol. Mar 2020;19(3):271-278. doi:10.1016/S1474-4422(19)30368-0.
Taylor CA, Bouldin ED, McGuire LC. Subjective Cognitive Decline Among Adults Aged ≥45 Years — United States, 2015–2016. MMWR Morb Mortal Wkly Rep 2018;67:753–757. DOI: http://dx.doi.org/10.15585/mmwr.mm6727a1mm6727a1
Frumkin, K. Aging or Alzheimer’s? A Doctor’s Personal Guide to Memory Loss, Cognitive Decline, and Dementia, Skyhorse Publishing, November 2024.
Mitchell AJ, Beaumont H, Ferguson D, Yadegarfar M, Stubbs B. Risk of dementia and mild cognitive impairment in older people with subjective memory complaints: meta-analysis. Acta Psychiatr Scand. 2014 Dec;130(6):439-51. doi: 10.1111/acps.12336.
Dubois B, Hampel H, Feldman HH, et al. Preclinical Alzheimer’s disease: Definition, natural history, and diagnostic criteria. Alzheimers Dement. Mar 2016;12(3):292-323. doi:10.1016/j.jalz.2016.02.002.
Li H, Tan CC, Tan L, Xu W. Predictors of cognitive deterioration in subjective cognitive decline: evidence from longitudinal studies and implications for SCD-plus criteria. J Neurol Neurosurg Psychiatry. 2023 Oct;94(10):844-854. doi: 10.1136/jnnp-2022-330246. Epub 2023 Mar 3. PMID: 36868847
Drabo EF, Wolff JL, Chyr LC, Zissimopoulos J, Lau B. Subjective Cognitive Impairment (SCI) and Future Dementia Risk in the National Health and Aging Trends Study (NHATS) During 2012-2019. J Aging Health. 2025 Mar;37(3-4_suppl):76S-90S. doi: 10.1177/08982643241308450. Epub 2025 Mar 23. PMID: 40123187.
Kuhn E, Klinger HM, Amariglio RE, Wagner M, Jessen F, Düzel E, Heneka MT, Chételat G, Rentz DM, Sperling RA, Ebenau JL, Butterbrod E, Van Der Flier WM, Sikkes SAM, Teunnissen CE, Van Harten AC, Van De Giessen EM, Rami L, Tort A, Sánchez Benavides G, Gifford KA, Van Hulle C, Buckley RF; Alzheimer’s Disease Neuroimaging Initiative; Australian Imaging Biomarkers and Lifestyle flagship study of ageing, A4 Study Team; DELCODE Study; Harvard Aging Brain Study. SCD-plus features and AD biomarkers in cognitively unimpaired samples: A meta-analytic approach for nine cohort studies. Alzheimers Dement. 2025 May; 21(5): e14307. doi: 10.1002/alz.14307. Epub 2025 Feb 22. PMID: 39985404; PMCID: PMC12079645.
Earl Robertson F, Jacova C. A Systematic Review of Subjective Cognitive Characteristics Predictive of Longitudinal Outcomes in Older Adults. Gerontologist. 2023 May 9;63(4):700-716. doi: 10.1093/geront/gnac109. PMID: 35908232.
National Academies of Sciences E, Medicine, Division of B, et al. The National Academies Collection: Reports funded by National Institutes of Health. In: Forstag EH, ed. Implications for Behavioral and Social Research of Preclinical Markers of Alzheimer’s Disease and Related Dementias: Proceedings of a Workshop—in Brief. National Academies Press (US), 2021.
Tackling the ‘worried well’ in general practice. Practice Business, practicebusiness.co.uk, November 28, 2019
Hannah K, Marie K, Olaf H, Stephan B, Andreas D, Wilson Michael L, Till B, Peter D. The global economic burden of health anxiety/hypochondriasis- a systematic review. BMC Public Health. 2023 Nov 13;23(1):2237. doi: 10.1186/s12889-023-17159-5. PMID: 37957598; PMCID: PMC10644595.17.
Petersen RC. (2004). “Mild cognitive impairment as a diagnostic entity.” Journal of Internal Medicine, 256(3), 183–194. https://doi.org/10.1111/j.1365-2796.2004.01388.x