This content was created by Farzana Vela, MS, CCC-SLP, BSRC, RRT-NPS, with Continued AI assistance. The course has been reviewed by a subject-matter expert, Angela Ciccia, Ph.D., CCC-SLP.
To Learn More on This Topic: MCI: Assessment and Treatment - Course 11362
Learning Outcomes
After this course, participants will be able to:
- Differentiate subjective cognitive decline (SCD) from mild cognitive impairment (MCI) using SCD-Plus diagnostic criteria.
- Explain how age- and education-adjusted normative frameworks improve interpretation of cognitive screening results in adults with suspected MCI.
- Discuss evidence-based intervention components and modifiable risk factors relevant to MCI management in adults.
Introduction
You have a patient in front of you. She is 71 years old, a retired nurse, and her daughter scheduled this appointment without telling her why. She scored 27 out of 30 on a brief cognitive screen six months ago. She is confident, articulate, and mildly annoyed. Her daughter has a list.
This is the clinical reality of mild cognitive impairment. It rarely presents with a clear score and a compliant patient. More often, it arrives with competing data points, a concerned family member, and a patient who trusts her own self-assessment more than anyone else in the room.
The scale of the challenge is significant. Fifty million people worldwide live with dementia, and 7.2 million Americans have Alzheimer's disease (WHO, 2023; Alzheimer's Association, 2024). Livingston and colleagues' (2024) Lancet Commission found that nearly 45% of dementias are theoretically preventable through 14 modifiable risk factors. That statistic is the rationale for early identification and early intervention.
Speech-language pathologists are uniquely positioned in this landscape. We are often the first clinicians to notice subtle cognitive-communication changes. We have assessment tools within our scope that detect multi-domain impairment that brief screens miss. And we deliver structured cognitive intervention programs that the research shows can slow the progression of cognitive decline.
This course presents three clinical case studies designed around the ambiguity that characterizes real MCI practice — when the screen looks fine, but something is off; when the patient is unconcerned, but the family is not; and when the patient qualifies for intervention but the standard protocol will not connect. The clinical reasoning draws directly from the peer-reviewed literature anchoring this course.
Understanding the MCI Continuum
Mild cognitive impairment exists on a continuum, and understanding where a patient sits on that continuum determines how you assess and intervene.
Normal aging involves changes in processing speed and working memory that do not interfere with daily function. Subjective cognitive decline (SCD) occurs when an individual reports perceived cognitive changes despite normal objective performance. Previously dismissed as "the worried well," SCD research now shows it can represent the earliest stages of neurodegeneration in some individuals (Jessen et al., 2020).
MCI is distinguished from SCD by objective impairment on standardized testing. Per Petersen et al.'s (2018) guideline update, the three diagnostic criteria are: subjective concern about cognitive changes (from the patient or an informant); objective impairment, typically 1.0–1.5 standard deviations below the mean; and preserved activities of daily living. When ADLs are significantly affected, the diagnosis shifts to dementia.
Use Figure 1 at the start of any assessment conversation to orient the patient and family to where they sit on the continuum and why acting during the SCD-Plus to MCI window changes outcomes.
Figure 1. The Cognitive Continuum — from normal aging through SCD, SCD-Plus, MCI, and dementia. Original illustration. Frameworks: Jessen et al. (2020); Petersen et al. (2018); Belleville et al. (2021, 2024).
SCD-Plus: Not All Subjective Decline Is Equal
Jessen and colleagues (2020) introduced the SCD-Plus framework to identify features within the SCD population that increase the likelihood of progression to MCI and dementia. The six features are:
- A subjective memory complaint (specific to memory, not general cognition)
- Onset within the past 5 years
- Age over 60
- A high level of personal concern
- Informant confirmation
- Minor neurological signs
Not all must be present, but the more that are, the greater the clinical concern. See Figure 2 for the full feature breakdown and case mapping.
This framework matters clinically because it moves you beyond the binary of "screen passed" or "screen failed." A patient who reports memory concerns with informant confirmation and a recent onset may meet SCD-Plus criteria even without objective impairment, and that changes your clinical recommendation entirely. The screen isn't wrong; it's just not the whole picture.
Apply Figure 2 in your next evaluation when a screen score looks fine, but the clinical picture does not match. Three or more features present: proceed with a comprehensive assessment regardless of the screen score.
Figure 2. SCD-Plus Six Risk Features (Jessen et al., 2020) and their application to Cases 1 and 2. Filled circles = feature present; gray = absent. Note: absence of patient concern does not invalidate SCD-Plus when other features are present. Original illustration.
Amnestic vs. Multi-Domain MCI
Not all MCI profiles carry the same conversion risk.
Amnestic MCI — memory as the primary domain — is associated with higher rates of Alzheimer's disease conversion. This is the profile most people picture when they hear "MCI," and for good reason: memory decline is often the earliest visible sign of an Alzheimer 's-type trajectory.
Multi-domain MCI, in which memory impairment co-occurs with deficits in language, attention, or executive function, also carries an elevated risk — particularly at 1.5 or more SD below the mean (Petersen et al., 2018). This profile is easy to underestimate, because no single domain looks alarming on its own. It's the combination that raises the flag.
This distinction shapes how urgently you act and how comprehensively you assess. A single-domain amnestic presentation may warrant close memory-focused monitoring. A multi-domain presentation warrants a broader net — you're no longer just watching one system, you're watching how several are holding up together.
What Brief Screens Can and Cannot Tell You
Brief cognitive screens — the MMSE, MoCA, and similar tools — are designed to efficiently detect significant cognitive impairment in primary care settings. What they are not designed to do is detect the subtle, multi-domain pattern of decline that characterizes early MCI, especially in individuals whose cognitive reserve is above the population average. A retired nurse with decades of compensatory strategies can score well on a brief screen while something real is still going on underneath.
The single-domain limitation is the most clinically significant constraint. A brief screen's total score tells you something about overall cognitive status, but little about the pattern of impairment across domains. Two patients can score identically with entirely different profiles underneath — one struggling with word retrieval, another with divided attention, both landing on the same number. The score flattens the very distinction that matters most for planning care.
The Arizona Battery for Cognitive Communication Disorders, Second Edition (ABCD-2; Bayles & Tomoeda, 2020) addresses this directly:
- Assesses multiple cognitive domains simultaneously
- Provides normative data specific to MCI and dementia populations
- Uses gradient difficulty to detect subtle impairments that flat-difficulty tools miss
When the ABCD-2 is unavailable, see the comparison table in the Thomas case section in Figure 4.
The Education Effect
Higher education is both a protective factor for dementia and a source of normative score inflation on brief screens. A retired professor or career professional may score 27 or 28 out of 30 while showing a meaningful decline from their own personal cognitive ceiling. The screen isn't lying — it's just answering a different question than the one that matters clinically.
The brief screen's norms reflect a population average. For individuals whose lifelong performance exceeded that average, a score that looks normal relative to the population may not be normal relative to them. This is the concept of cognitive reserve working against detection: the very strength that has masked decline so far is what makes the screen look reassuring.
When educational background is significant, and cognitive-communication changes seem incongruent with the screen score, trust the incongruence. The screen is not the whole picture — it's one data point, not the final word.
Case Study #1: Thomas — The Numbers Say Fine, But Do They?
Setting: 77-year-old retired professor, outpatient referral.
Scenario: Thomas scored 28 out of 30 on a brief cognitive screen administered by his primary care physician. His wife reports he has been having increasing difficulty finding words during conversation over the past several months — a change she describes as notable and recent. In the clinic, Thomas is cooperative and engaged. He says he feels perfectly sharp. His physician noted the score was within normal limits but referred to SLP due to the wife's concern.
Clinical Dilemma: Should a 28/30 brief screen score be sufficient to rule out MCI in a highly educated patient with a credible informant report of domain-specific decline?
Interactive Question
Thomas's wife reports a specific, recent decline in word-finding. His brief screen score is 28/30. Which assessment approach is MOST clinically appropriate?
A. Discharge — the brief screen is within normal limits and is sufficient.
B. Administer a comprehensive multi-domain battery using education-adjusted norms.
C. Refer directly to neurology without further SLP evaluation.
D. Rescreen in six months using the same brief tool.
Correct Answer: B. Administer a comprehensive multi-domain battery using education-adjusted norms.
The ABCD-2 (Bayles & Tomoeda, 2020) is designed for exactly this discussion. Its gradient-based difficulty detection identifies subtle impairments that brief screens miss, and its education-adjusted norms provide a more accurate baseline for Thomas, whose cognitive ceiling likely exceeds the population mean. A tool built around population averages was never going to catch what's happening with him — this one is built to.
His case also meets SCD-Plus criteria:
- Informant-confirmed domain-specific decline
- Recent onset
- Age over 60
Three features, all present, all pointing in the same direction. This is a case where the framework and the assessment tool reinforce each other — SCD-Plus tells you to look closer, and the ABCD-2 gives you a way to actually see what a brief screen would miss.
Use Figure 3 when documenting your clinical reasoning for choosing a comprehensive assessment. Name the path taken, the risk of the alternative, and the supporting evidence.
Figure 3. The Clinical Fork — Path A vs. Path B for Thomas. Path A (stop at screen score) risks missing the education ceiling and losing the intervention window. Path B (ABCD-2, education-adjusted norms) follows the evidence-based reasoning of Jessen et al. (2020) and Bayles & Tomoeda (2020). Original illustration.
Thomas's case meets SCD-Plus criteria (Jessen et al., 2020): informant-confirmed decline in a specific domain (word-finding), recent onset, and age over 60. His self-perception of being perfectly sharp is a clinical variable to work with, not a reason to close the case. He's not being difficult — he's giving you information. Use it.
Frame the ABCD-2 around what Thomas values — maintaining sharpness and catching changes early. This reframes the assessment from something his wife wants to something that serves his own stated goals. The battery stops being a test he's being subjected to and becomes a tool he's choosing to use. If Thomas declines the battery, document your recommendation and his response.
When the ABCD-2 Is Not Available
The ABCD-2 is the recommended tool for this population, but not every clinical setting has access to it — cost, training, or availability can all get in the way. If unavailable, the alternatives in Figure 4 provide a multi-domain assessment within the SLP scope. None offers the same MCI-specific normative data, but each extends meaningfully beyond a brief screen. Something is better than a single total score when the pattern of impairment is what matters.
Figure 4. Alternative multi-domain assessments.
Clinical Reasoning at the Assessment Fork
Two of the most common — and most consequential — clinical errors in MCI practice are false reassurance and informant dismissal.
False reassurance occurs when a normal or near-normal brief screen score is used to close the clinical question, even when the overall picture does not support that conclusion. The score becomes a stopping point instead of one piece of evidence among several.
Informant dismissal occurs when a patient's self-report of no concern overrides a credible, specific informant report of behavioral change. The patient's confidence gets treated as the final word, even when someone who sees them daily is describing something real.
Both errors share a common root: overreliance on the single most legible data point at the expense of the full clinical picture. A number is easy to trust because it feels objective. A family member's account is easy to dismiss because it feels subjective. But legibility isn't the same as accuracy.
The SCD-Plus framework provides a structured alternative that allows you to evaluate informant reports even when the patient disagrees — it gives that "soft" data a formal place in the clinical picture, rather than leaving it to compete informally with a test score.
The Ethics of Early Disclosure
A recurring clinical question is what to do when the patient does not want to know. Research consistently shows that most older adults say they would want early warning of cognitive decline. But a meaningful minority would not — and that preference deserves respect.
Respecting patient autonomy means presenting your clinical findings and recommendations clearly, then honoring the patient's decision. It does not mean withholding the recommendation. There's a real difference between "she doesn't want to know, so I won't tell her" and "she doesn't want to know, so I never assessed in the first place" — only one of those is patient-centered care.
Your obligation is to assess, recommend, and document. What happens after is a shared decision — but only after you have made your recommendation.
Case Study #2: Gloria — She's Not Worried, But Her Daughter Is
Setting: 71-year-old retired nurse, primary care referral, no self-reported concern.
Scenario: Gloria's daughter scheduled this appointment without informing her mother of the reason. Gloria scored 27 out of 30 on a brief cognitive screen at a routine primary care visit — within normal limits. Gloria is confident and mildly resistant: "I know what cognitive impairment looks like. I don't have it." Her daughter reports that Gloria has been repeating the same stories in conversation and has recently missed two family events she had confirmed attendance at, both within the last four months.
Clinical Dilemma: Does the absence of patient-reported concern, combined with a professional background in healthcare, justify not proceeding with cognitive assessment?
Interactive Question
Gloria reports no concern and states she understands cognitive impairment from her nursing background. Her daughter reports specific, recent behavioral changes. Which clinical action best reflects SCD-Plus criteria?
A. Defer to Gloria — she is a healthcare professional, and her self-assessment is authoritative.
B. Proceed with SCD-Plus analysis; the daughter's specific, recent report is clinically significant regardless of Gloria's self-perception.
C. Request a family meeting without Gloria to gather more information before proceeding.
D. Administer a brief screen and discharge if results are within normal limits.
Correct Answer: B. Proceed with SCD-Plus analysis; the daughter's specific, recent report is clinically significant regardless of Gloria's self-perception.
Jessen et al. (2020) are explicit: absence of patient concern does not invalidate SCD-Plus when other features are present. Gloria's case includes informant-confirmed episodic decline (repeated stories, two missed events within four months), age over 60, and a specific, recent informant report.
Miebach et al. (2019) found that informant-confirmed episodic memory decline is associated with amyloid pathology — a meaningful clinical signal regardless of patient self-assessment. In other words, the daughter's report isn't just an anecdotal concern. It's tracking something that has a known biological correlate.
Gloria's professional background is both a complication and a clinical tool. She may rationalize away changes to protect her professional identity — but she also understands clinical data and the value of a baseline. Framing matters here: "As a nurse, you know the value of a baseline. This is yours," opens a very different conversation than "We're concerned about your memory." One invites her in as a colleague. The other puts her on the defensive.
Document regardless of Gloria's decision: informant report details, SCD-Plus features present, your clinical recommendation, and her response.
Evidence-Based Intervention for MCI
Belleville and colleagues' MEMO+ program (2021, 2024) is a structured eight-session group intervention emphasizing memory strategy instruction with explicit metacognitive components — teaching not only what strategies to use, but when and how to apply them. Wellness education covering sleep, nutrition, stress, and social connection is integrated throughout. Five-year follow-up showed maintained cognitive benefits and reduced conversion to dementia. That's a rare thing in this field — a durable result, not just a short-term bump.
The U.S. POINTER Study Team (2025) compared a structured, coach-supported lifestyle intervention against a self-guided version in over 2,000 older adults. Both groups improved — but the structured group did measurably better. The key finding: structure and accountability are not incidental features. They are active clinical ingredients. Handing someone a list of good habits is not the same intervention as walking through it with them, session by session.
The 14 Modifiable Risk Factors
Livingston and colleagues' (2024) Lancet Commission identified 14 modifiable risk factors accounting for approximately 45% of dementia cases:
- Early life: lower education
- Midlife: hearing loss, traumatic brain injury, hypertension, obesity, alcohol overconsumption, smoking
- Later life: depression, social isolation, physical inactivity, air pollution, diabetes, vision loss, elevated LDL cholesterol
For SLPs, the most directly actionable factors within clinical scope are social isolation, physical inactivity, and depression — all modifiable through intervention design and referral. Group programs addressing these are not just providing cognitive stimulation; they are systematically targeting known dementia risk factors. A weekly group isn't just "something to do" — it's hitting three of fourteen levers with real evidence behind them.
Use Figure 5 at intake to explain why the group program addresses more than memory. Name the modifiable risk factors specific to this patient — this makes the program's rationale concrete rather than generic.
Figure 5. Fourteen modifiable risk factors by life stage (Livingston et al., 2024), SLP-actionable factors for Case 3 highlighted, and MEMO+ four-component program structure (Belleville et al., 2021, 2024). Original illustration.
What a Memory Strategy Looks Like in Practice
MEMO+ strategy instruction is explicit and transferable — not a cognitive exercise for its own sake. The goal isn't to get better at a drill; it's to get better at remembering things that actually matter in daily life.
One core strategy is Name-Face Association, which directly targets the word-finding and recall deficits most common in amnestic MCI. Rather than relying solely on repetition, the strategy gives patients a concrete method — linking a distinctive facial feature to a name through a memorable image or phrase — that they can apply the next time they're introduced to someone, not just in the therapy room.
Strategy example: Name-Face Association
- Step 1 — Focus on one distinctive feature of the person's face (e.g., a prominent forehead or bright eyes).
- Step 3 — Link the image to the facial feature: the ray of sunlight shining off his forehead.
The metacognitive component: after the session, ask — when in your daily life will you use this? What situation will cue you? That transfer question is what MEMO+ research shows produces durable gains (Belleville et al., 2024). The strategy only works if it leaves the room with the patient — the question is what makes sure it does.
Sample Group Session Outline (Session 3 of 8)
- 0–10 min — Check-in and homework review: Each participant reports on one strategy attempt from the week. Group responds. Clinician reinforces effort, not outcome.
- 10–30 min — Strategy instruction: Introduce or deepen one strategy (e.g., spaced retrieval, visual association). Explicit modeling, then guided practice with participant-generated examples.
- 30–45 min — Cognitive stimulation activity: Graded task requiring application of the session's strategy — not a standalone worksheet. Difficulty calibrated to the group's current level.
- 45–55 min — Wellness education segment: One modifiable risk factor addressed briefly. This week: physical activity and neuroplasticity. Each participant sets one concrete, achievable weekly goal.
- 55–60 min — Homework assignment: "Try this strategy once before next session and note what happened." Written on a card. Accountability partner named within the group if possible (U.S. POINTER Study Team, 2025).
Case Study #3: Raymond — He Qualified for the Group. Now What?
Setting: 69-year-old former contractor, community cognitive intervention group, confirmed mild amnestic MCI.
Scenario: Raymond's wife passed away 14 months ago. He was referred to a community cognitive intervention group after scoring 1.5 standard deviations below the mean on episodic memory tasks, with preserved ADLs. At intake, Raymond is polite but disengaged. He attends sessions but participates minimally. He mentions he "used to go to things" with his wife, but hasn't "seen the point" since she died. He lives alone.
Clinical Dilemma: Raymond meets diagnostic criteria for the group. But the standard protocol is not connecting to anything he currently cares about. What does individualization within a structured program look like for this patient?
Interactive Question
Which of the following is a modifiable risk factor for dementia, according to Livingston et al. (2024), that is DIRECTLY and clinically relevant to Raymond's current presentation?
A. Age — Raymond is 69 years old.
B. Amnestic MCI — his diagnosis places him at elevated conversion risk.
C. Social isolation — his withdrawal from community activities since his wife's death is a modifiable risk factor.
D. Male sex — men with MCI show faster progression in some studies.
Correct Answer: C. Social isolation — his withdrawal from community activities since his wife's death is a modifiable risk factor.
Age, MCI diagnosis, and sex are non-modifiable. Social isolation is explicitly listed among Livingston et al.'s (2024) 14 modifiable risk factors. Raymond's withdrawal is not background history — it is an active, modifiable contributor to his dementia risk within the scope of cognitive group intervention.
The clinical implication: Raymond's group participation is not about abstract cognitive stimulation — it is social re-engagement, a known modifiable dementia risk factor. Making this explicit gives him a concrete reason to attend. "Come do memory exercises" is a hard sell. "Your isolation is something we can actually change, starting here" is a different conversation entirely.
Clinical Language for Engaging Raymond
- On the purpose of the group:
- "Raymond, the research shows that staying socially connected is one of the most powerful things you can do to slow this process. This group is not just somewhere to learn strategies — it is how you stay connected. Showing up is the intervention."
- On building accountability without a care partner:
- "Between sessions, try one strategy and take one note about how it went. Bring it back next week — the group will ask. They're your accountability partner now."
- On addressing grief and low motivation:
- "I hear that things feel different since you lost your wife. Part of what we do here is build new routines — not to replace what you had, but to keep your mind and your connections active."
Depression screening is also warranted. Grief after spousal loss is not pathology, but depression — itself a modifiable risk factor — is not uncommon. A brief validated screen and warm referral to counseling, framed as part of a brain health plan, is appropriate and within scope. The line between grief and depression isn't always obvious in the room, which is exactly why a validated screen — not clinical impression alone — should be the one making that call.
The U.S. POINTER finding (2025) applies directly: structured, accountable programs outperform self-guided approaches. For Raymond, who lives alone, the group itself is the accountability structure. Build that from session one.
Putting It Together — Clinical Implications for SLPs
The three cases illustrate that the SLP's role in the MCI continuum extends beyond intervention delivery. It spans identification, assessment, intervention, referral, and documentation — and at each stage, clinical reasoning is required, not just clinical knowledge. Knowing the criteria is necessary. Knowing how to apply them to a specific, ambiguous patient in front of you is the actual skill.
Identification means observing cognitive-communication changes across your caseload and knowing the SCD-Plus features that warrant follow-up. It means trusting a reliable informant's specific, recent report even when the patient's self-assessment differs. It means not letting a brief screen score close a clinical question that the full picture suggests should remain open.
Assessment means using tools that provide multi-domain, normed data — particularly for patients whose educational backgrounds put their cognitive ceiling above the population mean. Comprehensive assessment is not an escalation; it is good clinical practice when the clinical picture warrants it.
Intervention means delivering structured programs with strategy instruction, wellness education, cognitive stimulation, and accountability — and individualizing within that structure. Raymond needs social re-engagement as a named treatment target. Thomas needs framing that aligns with his identity as a cognitively sharp person. Gloria needs clinical language and data, not emotional appeals. Same protocol, three different doors in.
3 Immediate Practice Changes
- Apply SCD-Plus criteria before closing any adult who presents with a near-normal brief screen and any informant concern. Document the features present.
- When education or professional background is significant, note the education effect explicitly in your assessment rationale and consider a multi-domain tool with education-adjusted norms.
- In your next cognitive group intake, identify one modifiable risk factor from Livingston et al. (2024) present in the patient's current life — social isolation, physical inactivity, depression — and name it explicitly as an intervention target.
These aren't new skills. They're the same clinical judgment you already use, applied a little earlier and a little more deliberately.
Documentation Considerations
Document the specific SCD-Plus features present, the informant report details, the assessment tools used and rationale, the intervention plan, and any patient refusals with your recommendation on record. In a field where the difference between SCD and early MCI can determine whether intervention begins before or after significant cognitive loss, this documentation matters considerably. It's not paperwork for its own sake — it's the record that shows your reasoning held up, whichever way the case went.
When to Refer and When to Lead
SLPs lead when a cognitive-communication assessment is warranted, a structured cognitive group intervention is indicated, and care team coordination is needed. Refer to neurology for diagnostic workup, neuropsychology for comprehensive neuropsychological evaluation, counseling for grief or depression, and primary care for modifiable risk factor management, including hypertension, diabetes, or hearing loss. Leading and referring aren't competing instincts — knowing which one a given moment calls for is itself part of the clinical skill.
Conclusion
The title of this course is a clinical argument: the score is one data point. It is not the whole picture — and in the context of MCI identification and intervention, it is often not even the most important one.
Thomas's 28 out of 30 did not resolve the clinical question because education, informant report, and domain-specific decline pointed in different directions. Gloria's confidence did not outweigh her daughter's specific, recent, informant-confirmed observations. Raymond's attendance at the group did not equal engagement — because engagement begins when the intervention connects to what matters to the patient. Three different patients, three different data points that looked reassuring on the surface, three cases where the surface wasn't enough.
Across all three cases, the clinical skill is the same: the ability to hold the full picture, reason from the evidence, and act on what you know — even when it conflicts with the most visible data point. That is clinical reasoning. And it is where your work has the power to change a trajectory — by recognizing what others might miss, intervening earlier, and anchoring care in what truly matters to the person in front of you.
Questions and Answers
Q: How does this framework apply to bilingual or multicultural patients?
A: SCD-Plus, the ABCD-2, and standard brief-screen norms are built primarily on English-speaking, Western-educated samples. When a patient's language background or educational history doesn't match those norms, use interpreters or culturally and linguistically matched assessment tools where available, weight informant report more heavily, and document the normative mismatch explicitly in your clinical reasoning rather than applying population norms uncritically..
Q: What should I rule out before applying SCD-Plus or MCI criteria?
A: Depression, untreated hearing loss, thyroid dysfunction, sleep apnea, and certain medications can all produce a cognitive-communication picture that mimics MCI. A brief depression screen and a review of hearing status and current medications are reasonable first steps before treating a presentation as neurodegenerative, and a positive finding in any of these areas warrants addressing or ruling out before proceeding with the SCD-Plus or MCI workup.
Q: Is this work billable, and can it be delivered via telehealth?
A: Coverage and telehealth eligibility for cognitive-communication assessment and group intervention vary by payer, state, and practice setting, so confirm current CPT code coverage and telehealth policy with your specific payer before billing. Much of the ABCD-2 and group intervention work involves behavioral observation, which can be harder to capture reliably via telehealth — weigh that against your setting's telehealth infrastructure and the patient's needs.
Q: What if a patient has no informant or family member to provide collateral report?
A: SCD-Plus and MCI diagnostic criteria both allow for patient self-report alone when no informant is available, though the absence of collateral information is itself a clinical limitation worth documenting. For isolated patients, lean more heavily on standardized, norm-referenced testing, and consider whether the social isolation itself should become a treatment target — as it did for Raymond
Q: When should I refer to neuropsychology instead of proceeding with a comprehensive SLP assessment like the ABCD-2?
A: Refer to neuropsychology when the clinical picture is diagnostically ambiguous, when results will inform a formal dementia diagnosis or capacity determination, when multiple domains are affected in a complex or atypical pattern, or when the patient or family needs a differential diagnosis beyond the SLP's scope. The ABCD-2 and similar tools are well-suited to characterizing cognitive-communication impairment and guiding intervention, but they are not a substitute for a full neuropsychological workup when one is clinically indicated.
Q: Do newer blood-based Alzheimer's biomarkers change any of this?
A: Blood-based biomarkers such as plasma p-tau217 are an active and fast-moving area of research and are increasingly used in specialty and research settings to support diagnosis, but they are ordered and interpreted by physicians, not SLPs, and do not change the SCD-Plus or MCI criteria described in this course. If a patient mentions biomarker testing or results, that information can inform your clinical picture and referral decisions, but it remains outside the SLP's scope to order or interpret.
References
- Alzheimer's Association. (2024). Alzheimer's disease facts and figures. Alzheimer's & Dementia.
- Bayles, K. A., & Tomoeda, C. K. (2020). Arizona Battery for Cognitive Communication Disorders (2nd ed.). Pro-Ed.
- Belleville, S., et al. (2021). Memory training in older adults with mild cognitive impairment: Positive effects are found five years after MEMO training. Alzheimer's Association International Conference. https://doi.org/10.1002/alz.055187
- Belleville, S., et al. (2024). Five-year effects of cognitive training in individuals with mild cognitive impairment. Alzheimer's & Dementia: Diagnosis, Assessment & Disease Monitoring, 16, e12626. https://doi.org/10.1002/dad2.12626
- Jessen, F., et al. (2020). The characterisation of subjective cognitive decline. The Lancet Neurology, 19(3), 271–278. https://doi.org/10.1016/S1474-4422(19)30368-0
- Livingston, G., et al. (2024). Dementia prevention, intervention, and care: 2024 report of the Lancet Standing Commission. The Lancet, 404(10452), 572–628. https://doi.org/10.1016/S0140-6736(24)01444-1
- Miebach, L., et al. (2019). Which features of subjective cognitive decline are related to amyloid pathology? Alzheimer's Research & Therapy, 11(1), 1–14. https://doi.org/10.1186/s13195-019-0515-y
- Petersen, R. C., et al. (2018). Practice guideline update summary: Mild cognitive impairment. Neurology, 90(3), 126–135. https://doi.org/10.1212/WNL.0000000000004826
- U.S. POINTER Study Team. (2025). Structured vs self-guided multi-domain lifestyle interventions for global cognitive function. JAMA, 334(8), 681–691. https://doi.org/10.1001/jama.2025.12923
- World Health Organization. (2023). Dementia. WHO Fact Sheet.
Citation
Vela, F. (2026). What the Score Doesn't Tell You: Clinical Reasoning in Mild Cognitive Impairment. Continued.com - SpeechPathology.com, Article 20800. Available at https://www.speechpathology.com/.
