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Does “one size fit all” in subjective cognitive decline?

As the population ages, age-related cognitive decline is becoming a well-documented public health crisis, for which no therapeutic treatment is available. Cognitive decline exists on a continuum from slight and subjective cognitive changes, a condition referred to as subjective cognitive decline (SCD), to dementia. Although dementia is a condition that stems from several different neurodegenerative diseases, it is commonly characterized by cognitive and functional impairment, which require assistance for basic daily activities and leads to increased psychological distress and family burden. However, even in the earliest stage of this continuum, when cognitive alterations are slight or only subjective, a certain degree of support or assistance might be needed, as individuals experience increasing difficulty with daily activities, such asmedication management or appointment scheduling. Indeed, although SCD, by definition, is absent of objective cognitive impairment on the basis of clinical evaluation, no universally accepted cutoff exists to differentiate SCD from objective cognitive impairment (Jessen et al., 2020). Moreover, standardized evaluations commonly used to assess the degree of cognitive impairment might not be able to capture subtle cognitive alterations in individuals with strong cognitive profiles (e.g. individuals with high cognitive reserve) – and these assessments might be culturallyspecific. Finally, SCD is a heterogeneous phenotype, with different underlying pathophysiological processes linked with specific needs, which, ultimately, might be neglected by relatives and primary care physicians, due to its intrinsic nature (i.e. subjective complaints do not match with objective findings). Thus, identifying the unmet needs of individuals with SCD and the associated sociodemographic characteristics might help to mitigate the impact of developing difficulties with day-to-day activities and the associated mental and/or physical burden. Moreover, understanding unmet needs in this population might help to guide new early interventions to improve the quality of life of patients facing cognitive decline and their families. Bouldin et al. (2020), in their population-based cohort study, provided a thoughtful overview of the prevalence of unmet needs in SCD individuals aged 45 years and older in the US, and the relatedmental, physical, and social features. The main finding was that 40% of individuals with SCDwho need help are not getting it. Upon deeper examination, their findings point to larger trends and patterns. Several characteristics were effect modifiers in the relationship between SCD and having unmet needs, including economic (e.g. household income, living status), psychological (e.g. mental distress, depression), and sociodemographic (e.g. age, ethnicity) factors. Therefore, beyond the report that a vast number of SCD individuals have unmet needs, this study eloquently suggests a large amount of heterogeneity in SCD care. Among these factors, Bouldin and colleagues reported that psychological factors, such as mental distress and depression, play a significant role in unmet needs. The result is consistent with findings suggesting that SCD often co-occurs with depression (Burmester et al., 2016), which has several implications for health services and practitioners involved in the care of older people. Evaluation of mental distress might be relevant to identify those SCD individuals with unmet needs. However, it is worthwhile to highlight that depression and SCDare two independent constructs that might independently lead to neurodegenerative disorders through different neurobiological pathways (Liew, 2019). Indeed, stratifying SCD individuals by depressive symptoms, Bouldin and colleagues reported that, after adjusting for sociodemographic factors, mental distress was associated with SCD-related unmet needs only among those who had never been diagnosed with depression. This result suggests that the relationship between depression and SCD is more convoluted thanmight have previously been thought (Liew, 2019). Recently, in a review of magnetic resonance imaging studies, we reported a heterogeneous neurodegenerative profile in SCD, which could depend on subclinical mental distress, such as anxiety and depression (Pini and Wennberg, under review). Taken together, this evidence suggests a heterogeneous pattern in SCD where psychological factors, including depression, might underlie different trajectories and needs. All of these factors should be carefully evaluated in terms of daily support and needs in SCD individuals. Other personality characteristics or sociodemographic factors could affect the relationship between SCD-related unmet needs and depression. As recently pointed out, the relationship betweenmood symptoms and SCD differs by ethnoracial group (Chapman, 2020).Meanwhile, studies have found that prevalence International Psychogeriatrics (2021), 33:7, 651–653 © International Psychogeriatric Association 2021