Executive impairment and informant-reported inhibition discrepancy in subjective cognitive complaints: comparative findings and neuropsychological care protocol proposal

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These changes, though often subtle, may result from various factors but could also signal underlying neurocognitive conditions, making early detection and intervention crucial. This study aimed to assess executive and emotional performance, to assess both the subject’s and the informant’s perceptions of cognitive complaints, and to develop a clinical care protocol for individuals attending neuropsychological consultations due to SCC. Seven neuropsychological tests (FSCRT, SDMT, INECO Frontal Screening, CF-7MS, Tower of London, BRIEF-A, Beck tests) were administered to 40 older adults: 20 clinical subjects (mean age: 71.8 ± 5.0) and 20 controls (mean age: 66.8 ± 4.0), including both sexes. Results showed a significant difference in overall executive performance between the clinical and control groups across sustained attention, memory recall, planning, cognitive flexibility, and processing speed, with the clinical group performing worse and, most importanly, exhibiting clinically significant scores. In comparing the subject’s and informant’s reports of cognitive complaints, agreement was found in all dimensions except Inhibition, where a notable discrepancy emerged: informants reported worse performance. No differences in emotion were observed between groups. Based on these findings, a clinical protocol centered on executive assessment is proposed, encompassing multiple cognitive domains, emotional questionnaires, self- and informant-reported complaints, functioning, and clinical-cognitive semiology. In conclusion, executive deficits may be present in patients with SCC, and executive assessment is a valuable tool for detecting possible prodromal neurocognitive changes. Implementing systematized protocols in clinical neuropsychological practice can strengthen primary health care, though future research should aim for a more established consensus. Subjective cognitive complaints Dementia Executive performance Neuropsychological assessment self- and informant report 1 Introduction The increase in life expectancy over the last century has been accompanied by an increase in the onset of various pathological conditions that continue to challenge health systems [1, 2?]. In the neurological field, the prevalence of neuropathological disorders associated with aging, particularly dementia, is increasing globally [ 2 ]. According to data from the World Health Organization (WHO), in 2021, around 57 million people worldwide had dementia, and more than 60% of them are in low- and middle-income countries. Furthermore, the number of cases is estimated to double by 2030 and increase even further by 2050 [ 3 ]. Identifying possible cognitive changes in their early and preclinical stages is essential for the initial phase of clinical diagnosis and for providing more timely, effective therapeutic interventions [ 4 ]. Currently, there are no clear parameters to differentiate between changes associated with normal and pathological brain aging [ 5 ]. In this regard, studies have identified structural and functional brain changes associated with normal aging [ 6 , 7 ], and others have found a relationship between cognitive decline and changes in certain brain regions [ 7 – 9 ]. However, no clinically useful data have yet been found. This lack of specificity is becoming increasingly important; it is a clinical challenge to promptly identify possible prodromal pathological changes in older adults, given that about 40% of this age group experiences "age-related cognitive decline" at some point, and another significant group progresses to pathological conditions [ 10 ]. With aging, due to various factors, the body becomes more vulnerable to disease [ 1 ]. Changes in cognitive performance in older adults are highly variable and depend on myriad factors, such as age, educational and premorbid level, emotional state, and self-perception, among others [ 11 ]. In addition, these changes can affect specific cognitive functions and may be accompanied by declines in various cognitive processes [ 5 ]. Moreover, SCC is an increasingly common condition that may be directly related to the progression to neurocognitive disorders such as dementia [ 12 – 14 ]. Therefore, this lack of precision in the clinical criteria for age-related cognitive changes and their possible relationship to the progression to a pathological condition has led to different conceptualizations of subjective cognitive complaints (SCC). Different authors have refined the term SCC to refer to entities of greater value in clinical practice. Thus, based on SCC, Subjective Cognitive Decline (SCD) has also been described as an entity initially developed in the context of impairment associated with neurodegenerative diseases such as AD; however, it now has broader utility in healthcare [ 13 , 15 ]. Initial SCD (SCD-I) is characterized by 1) self-perception of decreased cognitive performance compared to the previous cognitive level; and 2) absence of dysfunctional signs and normal performance on standardized cognitive tests adjusted for age, sex, and educational level [ 12 ]. In this same vein, knowing that SCD is not associated with progression to dementia in all individuals, prospective studies determined that subjects with SCD of 10 years' evolution were more likely to develop it. Therefore, the criteria for MCI plus were established: 1) subjective memory impairment, independent of impairment in other cognitive domains; 2) onset of MCI within the last 5 years; 3) onset of symptoms after age 60; 4) constant concerns associated with SCD; and 5) confirmation of cognitive impairment by an informant [ 13 ]. The conversion of symptoms over time from SCD to Mild Cognitive Impairment (MCI) and dementia is another key point in validating the need to study SCD from a neuropsychological perspective. Longitudinal studies have determined that SCD can progress in 27% of individuals to MCI and in 14% to dementia [ 16 – 17 ]. In addition, other authors have found that changes associated with SCD are accompanied by biomarkers of neurodegenerative diseases; therefore, their study remains a fundamental objective of recent research [ 18 – 22 ]. MCI is another heterogeneous clinical entity that, despite greater consensus regarding its characteristics, remains challenging to diagnose in clinical practice. There are different types of MCI: amnestic MCI, associated mainly with memory impairment (more related to the progression of AD); non-amnestic MCI, which affects cognitive domains other than memory (associated with the progression of frontotemporal dementia); multidomain amnestic MCI, which affects memory and other cognitive processes (related to AD or mixed vascular dementias); and multidomain non-amnestic MCI, associated with impairment of various cognitive processes, without memory being its main symptom (related to vascular dementia or Lewy body dementia) [ 23 , 24 ]. It should be noted that MCI is not the only entity associated with changes in cognitive performance; other clinical conditions, sometimes poorly established, such as Functional Cognitive Disorder (FCD), are currently being proposed, further complicating the criteria for accurate diagnosis [ 25 ]. Neuropsychological testing is an indispensable tool in all clinical diagnostic protocols for patients who present with subtle changes in cognitive performance. In addition, this clinical examination addresses issues that are not perceived in a screening assessment of general mental status or in the results of laboratory tests or neuroimaging [ 26 ]. Clinical assessment in this regard can be decisive in detecting early deficits associated with MCI and its progression to neurocognitive disorders, and is fundamental for objectively assessing the cognitive complaints reported by patients and their families [ 27 , 28 ]. Clinical analysis is based not only on the interpretation of the tests administered, but also on the context of each patient, including their functional performance in everyday activities [ 24 ]. In recent years, one line of research on the relationship between SCD and its potential progression to MCI and dementia has focused on determining the possible executive deficits that occur in its preclinical stages. Cognitive processes such as attentional and inhibitory control, working memory, planning, and cognitive flexibility, among others, would be involved [ 21 ]. Evidence of this, along with the contribution of more sensitive neurocognitive protocols in clinical evaluation, would mark a new approach to the early treatment of various neurocognitive disorders. Advances in studies of cognitive changes in the prodromal stages of neurocognitive conditions and their multifactorial relationships should remain an important line of current clinical research. Having more precise diagnostic criteria for early detection and access to standardized protocols will favor the implementation of more appropriate and relevant interventions. Therefore, the main objective of this research is to analyze executive performance and emotional state in people with subjective cognitive complaints who attend neuropsychological consultations, and to explore their possible value as early indicators of risk for MCI or other neurocognitive disorders. Thus, the specific objectives are: 1) to evaluate the executive performance of individuals with subjective cognitive complaints; 2) to describe the emotional state of the participants and its possible association with subjective cognitive complaints; 3) to compare the perception of cognitive impairment reported by participants with the external perception of an informant; and 4) to describe the findings of structural neuroimaging and complementary clinical diagnosis. Finally, based on the results obtained and the existing literature, a proposal for a clinical assessment protocol will be generated. 2 Methods Design and participants The study presents a quantitative, cross-sectional, observational approach with a relational scope. As part of the medical protocol following the initial assessment of patients at the Neurology Outpatient Clinic of Santa Inés Hospital (Cuenca, Ecuador), those with subjective cognitive complaints were referred to the Neuropsychology Outpatient Clinic for neuropsychological evaluation and to undergo complementary neuroimaging to achieve a differential diagnosis and establish appropriate treatment. A semi-structured clinical interview and a self-report questionnaire were developed for this study to obtain a brief, clinically focused assessment of difficulties with instrumental activities of daily living (IADLs) (see supplementary Table 1). The individual clinical interview was conducted in a single session by the primary researcher, the neuropsychologist at the outpatient clinic. After the interview and obtaining informed consent, patient data were included in the study if the patients met the selection criteria as follows: Inclusion criteria: being aged 60 years or older, having SCC, and signing the informed consent form. Exclusion criteria: patients with a prior diagnosis of advanced neurodegenerative disease and those with sensory limitations that precluded use of the instruments. The control subjects were mostly relatives of the clinical participants and participants with sociodemographic characteristics similar to those of the clinical group. Instruments According to the most recent literature [21], a neurocognitive testing protocol comprising seven tests was selected to assess various cognitive domains, with a primary focus on executive functions. An executive screening test such as the INECO frontal screening [29]; the Symbol Digit Modalities Test (SDMT) for attentional control [30]; the Verbal Fluency – Animals subtest of the Seven-Minute Screen Neurocognitive Battery (CF-7MS) [31]; an episodic verbal memory test for immediate and delayed recall such as the Free and Cued Selective Reminding Test – picture version (FCSRT) [32]; a test for planning and cognitive flexibility such as the Tower of London (ToL) [33]; and the Behavior Rating Inventory of Executive Function. Adult Version – Spanish Version (BRIEF-A) as a questionnaire (self-report/informant) on the perception of present cognitive complaints [34]. Finally, self-report questionnaires were used to assess levels of depression and anxiety, using the Spanish version of the Beck Depression Inventory-Fast Screen (BDI-FS) [35,36] and the Spanish version of the Beck Anxiety Inventory (BAI) [37,38]. The reference scores for each test are shown in Table 1. Table 1. Normative references and interpretation criteria for the neuropsychological instruments used TEST [reference] Process Index Values Sample Age (years) Nationality INECO Frontal Screening (IFS) [39] Executive functions Total score Cut-off score ≤ 23.5 suggests executive dysfunction 117 > 60 Peruvian SDMT [40] Attention/processing speed Total score Norms (Mean ± SD) Mean =34.9 SD = 10.7 316 65–85 Hispanic CF-7MS [31] Verbal fluency (animals) Total score Norms (Mean ± SD) Mean = 19 SD = 0.7 60 > 65 U.S. FCSRT [41] Episodic memory IFR Norms (Mean ± SD) Mean = 18.5 SD = 3.06 227 40–94 Italian ITR Norms (Mean ± SD) Mean = 23.9; SD = 0.36 DFR Norms (Mean ± SD) Mean = 10.07 SD = 1.85 DTR Norms (Mean ± SD) Mean = 11.97 SD = 0.16 Tower of London [33] Planning / problem solving Number of moves Norms (SS) Expected average range: 31–51 moves 347 > 60 British Total errors Norms (SS) Expected average: 0 errors Total initiation time Norms (SS) Expected average range: 25–63 seconds Total execution time Norms (SS) Expected average range: 361–230 seconds Total problem-solving time Norms (SS) Expected average range: 415–270 seconds BRIEF-A [34] Executive functions (ecological validity) Total score Cut-off score T > 65 considered clinically significant 1,500 18–90 U.S. BDI-SF (13 items) [36] Depressive symptoms Total score Clinical ranges 0–4 minimal; 5–8 mild; 9–13moderate; ≥14 moderate to severe > 1,000 16–90 U.S. BAI [38] Anxiety symptoms Total score Clinical ranges 0–7 minimal; 8–15 mild; 16–25 moderate; 26–63 severe 249 18–78 U.S. Note. Interpretation criteria were based on the normative studies and manuals specific to each instrument. Given the heterogeneity of scoring systems across neuropsychological measures (cut-off scores, normative data, standardized scores, and clinical ranges), interpretation followed the recommendations provided for each test rather than applying a single uniform criterion. SDMT: Symbol Digit Modalities Test; CF-7MS: Seven-Minute Seven Neurocognitive Battery; FCSRT- Free and Cued Selective Reminding; IFR: Immediate free recall; ITR: Immediate total recall; DFR: Delayed free recall; DTR: Delayed total recall; Test BRIEF-A: Behavior Rating Inventory of Executive Function. Adult Version; BDI-FS: Beck Depression Inventory-Fast Screen; BAI: Beck Anxiety Inventory; SS: Standard scores; SD: Standard Deviation. Ethical approval and consent to participate The study was approved by the Institutional review board (IRB) of the ‘Neuropsychology Outpatient Clinic’ (October 1, 2020) and was conducted in accordance with the ethical standards of the Declaration of Helsinki. All participants received a printed explanatory statement which included information about the study’s purpose, voluntary participation, potential risks, and confidentiality. Informed consent to use their data was obtained prior to participation. All responses were anonymised, and no personally identifying information was collected beyond general demographic characteristics. Data were stored on a password-protected, secure cloud server accessible only to the research team. Data analysis The information was processed in Jasp 0.18.1.0, and the results are shown using measures of central tendency and dispersion. The data were normally distributed according to the Shapiro-Wilk test (p > 0.05), so the parametric Student's t -test for independent samples was applied, and the effect size was determined using Cohen's d. The reference points stipulated by each author were used to interpret each test. A minimum statistical significance of 5% (< 0.05) was considered. 3 Results 3.1. Semi-structured interview including functional difficulties A semi-structured interview including a brief, clinically oriented assessment of functional difficulties in IADLs (see Supplementary Table 1) was administered individually to patients referred to the Neuropsychology Outpatient Clinic, as part of a broader neuropsychological assessment. 1.2. Participants This study involved 40 adults aged 60 years or older, comprising 20 clinical participants with SCC and 20 control subjects. Each group included 10 women and 10 men, matched by sex and educational level. All participants were assessed at the Neuropsychological Outpatient Clinic of Santa Inés Hospital in Cuenca, Ecuador. The mean age of the control group was 66.8 years (SD = 4.0), while that of the clinical group was 71.8 years (SD = 5.0). In terms of educational level, the two groups were similar: in the control group, 11 participants had completed secondary education and 8 had completed higher education; in the clinical group, 10 had completed secondary education and 9 had completed higher education, with 1 participant in each group reporting primary education. In terms of functionality, after a clinical interview, 8 participants in the clinical group had some functional limitations in instrumental activities of daily living (IADL). 3.3. Neurocognitive testing In accordance with the objectives set out, the results of each of them are described below, beginning with a presentation of the cognitive and emotional performance of the groups studied, the analysis of the perception of SCC according to the BRIEF-A, the findings of structural neuroimaging and complementary clinical diagnosis, and the proposed clinical protocol. 3.3.1. Cognitive and emotional performance (Table 2 ) Cognitive performance The executive performance of participants in the clinical group across several domains evaluated falls within the clinical percentile range, particularly in general executive performance (screening test), attentional control, verbal fluency, planning, cognitive flexibility, and memory recall. When comparing the performance between the clinical group and the control group, significant differences were identified in practically all tests, with the most absolute (*** p < 0.001) being those in executive screening tests (INECO frontal screening-Total Executive Performance) and episodic verbal memory recall processes (IFR and IFD – FCSRT). The second level of significance (** p < 0.01) shows differences in variables related to overall execution speed and cognitive flexibility (Execution Time and Errors in the Tower of London). Thirdly, (* p < 0.05) there are differences in planning processes (Number of Moves – London Tower), attentional control and processing speed (SDMT), immediate memory (ITR-FCSRT) and total delayed memory (DTR-FCSRT) (* p < 0.05). Finally, there are no significant differences in performance on verbal fluency tests (CF-7MS), impulsivity control (starting time – Tower of London), and working memory (INECO) between the groups studied. In the variable corresponding to qualitative errors (intrusions and perseverations) in the FCSRT test, only the clinical group presented this type of response (33 errors), whereas the control group did not (0 errors). This statistically significant difference ( *** p < 0.001) reflects a qualitatively different pattern of performance, rather than a simple quantitative variation in scores. The finding is clinically significant because it highlights a phenomenon present exclusively in the clinical group. Emotional performance The results for emotional aspects show no significant differences between the groups; furthermore, there are no clinically significant signs in either of the two areas evaluated; therefore, the sample shows no signs of anxiety-depressive symptoms that could interfere with their cognitive performance. Table 2 Cognitive and emotional performance DIMENSION of PERFORMANCE TEST / Process Control Mean (SD) Patient Mean (SD) t Statistics p Cohen's d COGNITIVE PERFORMANCE SDMT Attentional control/processing speed 33 (8.9) 26.8 (8.5) 2.25 .030* 0.71 INECO Executive performance (Total) 23.8 (2.7) 19.3 (3.6) 4.50 < .001*** 1.42 Working memory 6.8 (1.6) 6 (1.4) 1.69 .098 0.54 CF-7MS Categorical evocation (animals) 18.4 (4.4) 16.3 (4.4) 1.51 .140 0.48 Tower of London Planning (Movements) 48.7 (22) 64.4 (26) -2.08 .044* -0.66 Impulsivity control (Start time/sec) 38.5 (15) 47.6 (18) -1.75 .088 -0.55 Overall executive performance (Execution time/sec) 280 (147) 420 (223) -2.35 .024* -0.74 Overall executive performance (Total time/sec) 318 (152) 492 (203) -3.57 .004** -0.97 Cognitive flexibility (Errors) 1.1 (2.1) 5.4 (5.5) -3.20 .003** -1.01 FCSRT IFR 17.5 (1.5) 13 (3.2) 5.55 <..001*** 1.75 ITR 23.9 (0.3) 22.8 (1.9) 2.51 < .015* 0.81 DFR 9.3 (1.2) 5.8 (2.9) 5.04 < .001*** 1.59 DTR 11.9 (0.3) 11 (1.7) 2.42 .021* 0.76 Qualitative errors KW 33 (0) 0 (0) - <. 001*** - EMOTIONAL PERFORMANCE BDI-FS Depression 3.1 (2.5) 4.9 (4.1) -1.65 .106 -0.52 BAI Anxiety 8.1 (6.9) 11.6 (8.3) -1.43 .162 -0.45 Note: Group comparisons were performed using independent samples Student’s t-test (t), except for the variable of errors that was analyzed using non-parametric Kruskal-Wallis test ( KW ) due to the data distribution of the control group. Statistical significance: *** p < 0.001; ** p < 0.01; *p < 0.05 difference. 3.2. Perception of executive functioning (Table 3 ) After administering the self-report questionnaire and the informant report, concordance in the perception of executive deficits was assessed between the patient (self-report) and the family member (informant) for both the global and composite indices of executive functions and their respective dimensions. The only significant difference was observed in the Inhibition dimension, where family members reported greater difficulty in this aspect than the patient did (p < 0.05). Table 3 Executive functioning (BRIEF A) TEST Cognitive process Patient Family Statistics Mean (SD) CV (%) Mean (SD) CV (%) t p Cohen's d BRIEF A (Indices and Global Executive) GECT (Global Executive Composite) 60.6 (10.3) 0.17 59.8 (6.6) 0.11 0.332 .74 0.074 BRIT (Behavior Regulation Index) 59.4 (12.5) 0.21 58.5 (8.2) 0.14 0.359 .72 0.080 MIT (Metacognition Index) 60.3 (8.6) 0.14 60.0 (7.3) 0.12 0.134 .90 0.030 BRIEF A (Dimensions) Inhibition 53.2 (9.2) 0.17 58.1 (11.9) 0.21 -2.378 .03* -0.532 Flexibility 59.3 (11.3) 0.19 59.9 (9.8) 0.16 -0.163 .87 -0.036 Emotional control 61.3 (13.1) 0.21 57.8 (9.7) 0.17 1.299 .21 0.290 Self-control 55.1 (12.8) 0.23 54.7 (9.5) 0.17 0.199 .85 0.044 Initiative 54.5 (10.1) 0.19 56.7 (10.8) 0.19 -0.693 .50 -0.155 Working memory 67.5 (10.0) 0.15 70.5 (6.8) 0.10 -0.994 .33 -0.222 Planning 59.5 (9.7) 0.163 55.4 (9.3) 0.17 1.345 .20 0.301 Organization 59.5 (9.7) 0.163 55.4 (9.3) 0.17 1.345 .20 0.301 Task tracking 58.3 (9.1) 0.156 57.6 (7.8) 0.136 0.201 .84 0.045 Organization of materials 55.0 (11.3) 0.206 57.7 (8.7) 0.150 -0.947 .36 -0.212 3.3. Structural neuroimaging findings and clinical neurological diagnosis of the clinical group studied (Table 4 ) It should be noted that, as part of the medical protocol for evaluating the clinical group, participants were referred for neuropsychological assessment and requested to undergo complementary neuroimaging tests. The aim was to ensure that subjects who initially reported SCC at their first medical appointment could receive an appropriate diagnosis and treatment. After collecting medical information from the 20 subjects in the clinical group, it was determined that 14 (70%) showed significant findings on neuroimaging, including atrophy and cerebrovascular disease. Furthermore, after medical analysis of this information, supplemented by neuropsychological assessment, 16 participants (80%) met the diagnostic criteria for MCI (70%) and Alzheimer's disease (10%). These results support the clinical value of formal neuropsychological assessment within a multidisciplinary team. Table 4 Structural neuroimaging, diagnosis, and treatment (clinical group) Neuroimaging Clinica Data n Women:Men ratio % No data 6 3:3 30 Brain atrophy and cerebrovascular disease 5 2:3 25 Cerebral vascular disease 5 2:3 25 Brain atrophy 4 3:1 20 Diagnosis DCL 12 7:5 60 No definite diagnosis 3 1:2 15 DCL + depression/anxiety 2 1:1 10 Alzheimer's disease 2 1:1 10 DCL + depression/anxiety 2 1:1 10 Anxiety 1 1:0 5 Treatment Treatment - cognitive disorder 10 5:5 50 Treatment - Anxiety/Depression 5 3:2 25 No treatment 4 2:2 20 Treatment - cognitive disorder + anxiety/depression 1 0:1 5 Total 20 10:10 100 3.4. Proposed protocol Based on the results obtained and the absence of standardised protocols specifically guiding the clinical evaluation of these cases, it is considered necessary to propose its application in people with SCC, primarily to assess executive processes, given its possible predictive value in the preclinical stages of neurocognitive disorders. The protocol is based on a multidimensional model of executive functions, prioritising processes that have shown greater sensitivity to prodromal changes and that were assessed in our clinical study population. A sequential, standardised, and flexible clinical protocol for the assessment of cognitive functioning is proposed, designed to explore in an integrated manner the interaction between executive functioning and other cognitive processes. A two-phase protocol is proposed: Phase 1. Anamnesis and screening This includes an initial medical history (reason for consultation and characteristics of the subjective complaints), an executive screening test, a self-report/informant questionnaire on subjective complaints (with high ecological validity), and a questionnaire on anxiety-depressive symptoms. In this first phase, it is possible to identify areas that require specific evaluation or other factors that may be interfering with cognitive performance. Phase 2. Specific cognitive assessment An organized neuropsychological assessment containing a battery of tests in line with the objective of the assessment set out in phase 1 and based on relevant clinical criteria. It is suggested to start with an episodic memory test that incorporates visual stimuli (drawings), as this type of material is less dependent on language and educational level, thereby favoring its applicability across culturally diverse populations. The application of two initial learning trials is relevant for assessing coding ability, learning curve, and information retrieval strategies. Finally, after the interference interval, a delayed trial is applied. The interference interval consists of a stage in which associated cognitive processes are evaluated, including tests of categorical recall (lexical access and semantic organization), attentional control and processing speed, working memory, planning, and cognitive flexibility. Finally, the protocol concludes with the application of the delayed test (episodic memory), allowing evaluation of information consolidation, recall after interference, and determination of whether a possible memory deficit is due to failures in information retrieval or storage. An important element to consider is the presence or absence of dysfunctional clinical signs during neurocognitive task performance (intrusions, interference, and perseveration in episodic memory or categorical recall tests; errors in executive tasks; inhibitory errors; forgetting instructions, etc.). Below is a table outlining the cognitive domains and suggested tests/instruments that may be part of the clinical protocol (Table 5 ). This selection is based on the existing literature on the tools most commonly used in studies of SCC and DCL [ 42 ], as well as on studies that validate the tools used in this clinical study for patients with these characteristics [ 43 – 52 ]. Table 5 Proposal of a Neuropsychological Care Protocol in SCC Neuropsychological Care Protocol in Subjective Cognitive Complaints Phase 1. Anamnesis (semi-structured interview) and screening Phase 2. Specific cognitive and emotional assessment Domains Tests/instruments Process to be assessed Executive Functions TMT (A-B) Cognitive Flexibility Stroop Test Inhibitory control and attention ToL Planning, working memory, and cognitive flexibility Semantic & Phonological Fluency Verbal fluency as an executive measure Memory RAVLT Verbal learning WMS Immediate and remote memory FCSRT Consolidation and recall processes (episodic memory) Attention / Processing speed DST Working memory and attention SDMT Attention and processing speed Screening MMSE Cognitive screening IFS Executive screening Language BNT Verbal naming Semantic Fluency Semantic access and language Self-report/ informant report BRIEF A Questionnaire on perception of executive cognitive complaints Anxiety/ Depression BDI Depressive symptoms BAI Anxiety symptoms Functionality FAQ Instrumental functionality in daily activities Note: TMT (A-B): Trail Making Test; ToL: Tower of London; RAVLT: Rey Auditory Verbal Learning Test; WMS: Wechsler Memory Scale; IFS: INECO frontal screening, FCSRT: Free Cued Selective Remaining Test; MMSE: Mini-Mental State Examination; DST: Digit Span Test; BNT: Digit Span Test; BRIEF-A: Behavior Rating Inventory of Executive Function. Adult Version; BDI: Beck Depression Inventory; BAI: Beck Anxiety Inventory; FAQ: Functional Activities Questionnaire. Discussion The clinical criteria for diagnosis in the prodromal stages of possible neurodegenerative diseases continue to have considerable limitations. On the one hand, the conceptual shift in the terminology for cognitive complaints has enabled greater homogeneity in clinical evaluation criteria. The global, somewhat inconsistent view of the SCC construct has evolved toward more defined guidelines, such as SCD, which has operational criteria and is situated on the preclinical continuum of neurocognitive conditions, including Alzheimer's disease [ 12 , 13 ]. In this sense, a significant group of people with SCD is diagnosed with MCI when their cognitive decline is not sufficient for a diagnosis of dementia, and its etiology is multifactorial. However, not all patients with MCI progress to dementia or have established biological markers. For example, FCD is another clinical entity that can present with symptoms like MCI based on SCD; however, its etiology is not attributed to structural brain damage, it is usually reversible, and emotional factors also explain, in part, its progression. Improving the identification of SCD at its early stages, given the broad spectrum of underlying clinical and etiological conditions, would provide a better understanding of targeted early interventions [ 53 – 55 ]. Currently, clinical research in the early stages of these conditions is beginning to focus more on cognitive processes beyond memory, as was previously the case, supporting the unquestionable contribution of a formal and detailed neuropsychological assessment in all primary care protocols [ 56 ]. Several authors support focusing assessments on executive performance, where prodromal signs of neurodegenerative conditions appear, which would be of great clinical utility [ 57 , 58 ]. In the present study on executive and emotional performance in people with subjective cognitive complaints, relevant information is provided on the characterisation of this population, and functional neurocognitive tests are identified for clinical application. According to the set objectives, the clinical group, which initially presented with SCC, showed overall executive deficits across the cognitive dimensions studied, with performance significantly worse than that of the control group. These data are corroborated by the literature, where several studies emphasise executive assessment in the preclinical stages of MCI and corroborate this possible relationship between executive deficits and progression to MCI and dementia [ 59 – 68 ]. In this sense, executive deficits can be reflected in poor performance in processes such as decision-making, planning, cognitive flexibility, and processing speed [ 43 , 69 , 70 ], as well as in attentional control and working memory, which appear to be a cornerstone of these deficits in this population [ 71 – 75 ]. Research on cognitive performance in the prodromal stages of dementia remains inconsistent regarding the protocols to follow and the specific tools to use. The sole application of screening tools does not appear sufficiently viable or sensitive in the clinical context, even though some research shows the validity of tools such as the IFS for detecting early-onset cognitive impairment [ 44 ]. In addition, certain reviews argue that, in addition to screening tests, studies should consider other specific tools to assess processes such as memory, language, and executive function [ 42 , 76 ], as well as the use of self-report questionnaires/informant reports [ 45 , 77 ]. In line with this, the present study followed this assessment route, which, using various tools, focused on executive processes without neglecting the evaluation of other cognitive domains, such as language (verbal fluency) and memory. In turn, although the scores on the self-report/informant questionnaire for subjective complaints did not reach clinical significance, the concordance between the reports confirms the need to include them in the clinical protocol. For its part, memory, a complex, multimodal cognitive construct that requires the activation of several brain circuits, has shifted from being assessed globally to being understood specifically through its dimensions. For example, beyond the importance of limbic circuits, the prefrontal cortex has been shown to contribute to several processes and dimensions, such as memory recall and working memory [ 78 , 79 ]. The performance of our clinical group on episodic memory tests showed significantly lower recall processes compared to the control group, along with a higher number of pathological signs, such as intrusions, perseverations, and interferences. Dimensions such as memory recall and working memory have been linked to executive control, and studies have shown that patients with MCI and mild AD exhibit greater problems with recall processes and tools for information retrieval than with storage and consolidation [ 78 – 80 ]. The presence of intrusions and perseverations in this type of test also has significant predictive value in the preclinical stages of dementia [ 81 , 82 ]. Finally, the use of tests with visual elements (drawings), such as the one used in this study (FSCRT), has been shown to have greater validity due to its easy applicability to different populations without depending on factors such as language, culture, and educational level; it is also more accurate in discriminating between MCI and AD [ 46 , 83 ]. Although the present study did not find significant signs of anxiety or depression, nor did it determine a direct relationship between cognitive performance and the presence of signs of anxiety and/or depression, several studies indicate that the presence of symptoms of anxiety and/or depression is associated with a higher probability of developing MCI and dementia. Likewise, there is a group of subjects whose cognitive performance may worsen due to these clinical symptoms, sometimes making it difficult to accurately diagnose the primary disorder [ 84 – 86 ]. Furthermore, the literature has also supported a possible relationship between SCD, MCI, and the early stages of some dementias, with structural changes in specific brain regions. Lower executive performance would be associated with structural changes across cortical and subcortical areas, particularly in the frontal region [ 87 – 90 ]. In the present study, a significant proportion of subjects showed structural changes on neuroimaging studies, which, although not conclusive, would support a possible relationship with low executive performance. The proposal for a clinical protocol in the present study is supported by the lack of consistency in the neuropsychological assessment methods used across multiple studies. Despite being considered a key component of any MCI care protocol, there remains a need for more uniform, evidence-based clinical guidelines grounded in longitudinal studies and clinical follow-up [ 91 ]. Cognitive semiology is also an essential element in its interpretation. Although normative scores provide relevant quantitative information, they do not reflect the complexity of cognitive functioning or the mechanisms underlying performance, which can be objectified through qualitative analysis [ 81 , 82 , 92 ]. Finally, regarding the limitations of the study, it should be noted that the results obtained in this research are from an outpatient clinical context and may therefore not be entirely generalizable to other contexts and/or populations. However, they do allow us to approximate the behavior of this clinical group as a guide to appropriate, early, timely intervention. The data on structural neuroimaging, diagnosis, and treatment should be followed up with a longitudinal study of this sample to provide greater precision on the objectives set and on their possible conversion to other clinical entities. Conclusions The poorer executive performance in the clinical group with subjective cognitive complaints empirically supports the conceptual reformulation proposed in recent literature, where complaints are no longer considered a nonspecific subjective phenomenon but are integrated into the concept of Subjective Cognitive Decline. This study suggests that self-perception of changes in cognitive performance could be associated with objectifiable executive alterations, supporting its predictive and clinical value. According to the results, the clinical group showed poor overall cognitive performance, with most scores falling within clinically indicative ranges. There were significant differences from the control group in domains such as overall executive performance, attentional control, memory recall, planning, cognitive flexibility, and processing speed, as well as in the presence of qualitative errors, such as intrusions and perseverations. Emotional performance showed an absence of anxiety-depressive symptoms, with no significant differences between the clinical group and the control group. There was agreement between the clinical group's perception of the executive deficits present (self-report) and the perception of a family member (informant), with a significant difference in the dimension of inhibition, where family members perceive greater difficulties. The results of structural neuroimaging and complementary clinical diagnosis determined that most of the clinical group showed clinically significant data, such as signs of atrophy and cerebrovascular disease, after which they were diagnosed with MCI and/or Alzheimer's disease. A proposal for a clinical protocol is presented, outlined, and applicable to the clinical setting, focusing mainly on the assessment of executive processes, along with other important cognitive domains such as memory and language. A flexible protocol that also includes self-report questionnaires and informant reports on anxiety-depression symptoms and functionality. Finally, future research needs to delve deeper into other variables that may interfere with the relationship between SCD and its possible predictive value for the development of neurodegenerative conditions, carry out longitudinal and follow-up designs, as well as correlational studies with biomarkers that allow more specific parameters to be established, thus guiding more appropriate intervention in this population. Declarations Funding: The present work was performed without funding. Ethics approval and consent to participate: All participants provided written informed consent prior to inclusion in the study. Consent for publication: Not applicable. Availability of data and materials: The datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9059640","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":627948401,"identity":"8ae2fcb6-e547-4cf4-806a-778c62f65db2","order_by":0,"name":"Felipe Webster-Cordero","email":"data:image/png;base64,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","orcid":"","institution":"Autonomous University of Barcelona","correspondingAuthor":true,"prefix":"","firstName":"Felipe","middleName":"","lastName":"Webster-Cordero","suffix":""},{"id":627948402,"identity":"afb161b6-af7e-4950-86ac-c8e78fe5f5c8","order_by":1,"name":"Lydia Giménez-Llort","email":"","orcid":"","institution":"Autonomous University of Barcelona","correspondingAuthor":false,"prefix":"","firstName":"Lydia","middleName":"","lastName":"Giménez-Llort","suffix":""}],"badges":[],"createdAt":"2026-03-07 15:53:31","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9059640/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9059640/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108006012,"identity":"9c04ea32-9908-43a1-984d-e318f8837db1","added_by":"auto","created_at":"2026-04-28 12:51:53","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":642489,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9059640/v1/0360caff-3c40-4bd8-abfe-4cf8e115e5ed.pdf"},{"id":107625751,"identity":"fa40e53b-d561-498d-a158-58f7622e66cf","added_by":"auto","created_at":"2026-04-23 10:34:15","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":17151,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryTable1.Clinicalinterviewselfreportquestionnairedevelopedforthisstudy23MARCH.docx","url":"https://assets-eu.researchsquare.com/files/rs-9059640/v1/3caf2c40ef10b72156343a92.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Executive impairment and informant-reported inhibition discrepancy in subjective cognitive complaints: comparative findings and neuropsychological care protocol proposal","fulltext":[{"header":"1 Introduction","content":"\u003cp\u003eThe increase in life expectancy over the last century has been accompanied by an increase in the onset of various pathological conditions that continue to challenge health systems [1, 2?]. In the neurological field, the prevalence of neuropathological disorders associated with aging, particularly dementia, is increasing globally [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. According to data from the World Health Organization (WHO), in 2021, around 57\u0026nbsp;million people worldwide had dementia, and more than 60% of them are in low- and middle-income countries. Furthermore, the number of cases is estimated to double by 2030 and increase even further by 2050 [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Identifying possible cognitive changes in their early and preclinical stages is essential for the initial phase of clinical diagnosis and for providing more timely, effective therapeutic interventions [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCurrently, there are no clear parameters to differentiate between changes associated with normal and pathological brain aging [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In this regard, studies have identified structural and functional brain changes associated with normal aging [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], and others have found a relationship between cognitive decline and changes in certain brain regions [\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. However, no clinically useful data have yet been found. This lack of specificity is becoming increasingly important; it is a clinical challenge to promptly identify possible prodromal pathological changes in older adults, given that about 40% of this age group experiences \"age-related cognitive decline\" at some point, and another significant group progresses to pathological conditions [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWith aging, due to various factors, the body becomes more vulnerable to disease [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Changes in cognitive performance in older adults are highly variable and depend on myriad factors, such as age, educational and premorbid level, emotional state, and self-perception, among others [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. In addition, these changes can affect specific cognitive functions and may be accompanied by declines in various cognitive processes [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Moreover, SCC is an increasingly common condition that may be directly related to the progression to neurocognitive disorders such as dementia [\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Therefore, this lack of precision in the clinical criteria for age-related cognitive changes and their possible relationship to the progression to a pathological condition has led to different conceptualizations of subjective cognitive complaints (SCC).\u003c/p\u003e \u003cp\u003eDifferent authors have refined the term SCC to refer to entities of greater value in clinical practice. Thus, based on SCC, Subjective Cognitive Decline (SCD) has also been described as an entity initially developed in the context of impairment associated with neurodegenerative diseases such as AD; however, it now has broader utility in healthcare [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Initial SCD (SCD-I) is characterized by 1) self-perception of decreased cognitive performance compared to the previous cognitive level; and 2) absence of dysfunctional signs and normal performance on standardized cognitive tests adjusted for age, sex, and educational level [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. In this same vein, knowing that SCD is not associated with progression to dementia in all individuals, prospective studies determined that subjects with SCD of 10 years' evolution were more likely to develop it. Therefore, the criteria for MCI plus were established: 1) subjective memory impairment, independent of impairment in other cognitive domains; 2) onset of MCI within the last 5 years; 3) onset of symptoms after age 60; 4) constant concerns associated with SCD; and 5) confirmation of cognitive impairment by an informant [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe conversion of symptoms over time from SCD to Mild Cognitive Impairment (MCI) and dementia is another key point in validating the need to study SCD from a neuropsychological perspective. Longitudinal studies have determined that SCD can progress in 27% of individuals to MCI and in 14% to dementia [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. In addition, other authors have found that changes associated with SCD are accompanied by biomarkers of neurodegenerative diseases; therefore, their study remains a fundamental objective of recent research [\u003cspan additionalcitationids=\"CR19 CR20 CR21\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMCI is another heterogeneous clinical entity that, despite greater consensus regarding its characteristics, remains challenging to diagnose in clinical practice. There are different types of MCI: amnestic MCI, associated mainly with memory impairment (more related to the progression of AD); non-amnestic MCI, which affects cognitive domains other than memory (associated with the progression of frontotemporal dementia); multidomain amnestic MCI, which affects memory and other cognitive processes (related to AD or mixed vascular dementias); and multidomain non-amnestic MCI, associated with impairment of various cognitive processes, without memory being its main symptom (related to vascular dementia or Lewy body dementia) [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. It should be noted that MCI is not the only entity associated with changes in cognitive performance; other clinical conditions, sometimes poorly established, such as Functional Cognitive Disorder (FCD), are currently being proposed, further complicating the criteria for accurate diagnosis [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eNeuropsychological testing is an indispensable tool in all clinical diagnostic protocols for patients who present with subtle changes in cognitive performance. In addition, this clinical examination addresses issues that are not perceived in a screening assessment of general mental status or in the results of laboratory tests or neuroimaging [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Clinical assessment in this regard can be decisive in detecting early deficits associated with MCI and its progression to neurocognitive disorders, and is fundamental for objectively assessing the cognitive complaints reported by patients and their families [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Clinical analysis is based not only on the interpretation of the tests administered, but also on the context of each patient, including their functional performance in everyday activities [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn recent years, one line of research on the relationship between SCD and its potential progression to MCI and dementia has focused on determining the possible executive deficits that occur in its preclinical stages. Cognitive processes such as attentional and inhibitory control, working memory, planning, and cognitive flexibility, among others, would be involved [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Evidence of this, along with the contribution of more sensitive neurocognitive protocols in clinical evaluation, would mark a new approach to the early treatment of various neurocognitive disorders.\u003c/p\u003e \u003cp\u003eAdvances in studies of cognitive changes in the prodromal stages of neurocognitive conditions and their multifactorial relationships should remain an important line of current clinical research. Having more precise diagnostic criteria for early detection and access to standardized protocols will favor the implementation of more appropriate and relevant interventions. Therefore, the main objective of this research is to analyze executive performance and emotional state in people with subjective cognitive complaints who attend neuropsychological consultations, and to explore their possible value as early indicators of risk for MCI or other neurocognitive disorders. Thus, the specific objectives are: 1) to evaluate the executive performance of individuals with subjective cognitive complaints; 2) to describe the emotional state of the participants and its possible association with subjective cognitive complaints; 3) to compare the perception of cognitive impairment reported by participants with the external perception of an informant; and 4) to describe the findings of structural neuroimaging and complementary clinical diagnosis. Finally, based on the results obtained and the existing literature, a proposal for a clinical assessment protocol will be generated.\u003c/p\u003e"},{"header":"2 Methods","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eDesign and participants\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study presents a quantitative, cross-sectional, observational approach with a relational scope.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAs part of the medical protocol following the initial assessment of patients at the Neurology Outpatient Clinic of Santa In\u0026eacute;s Hospital (Cuenca, Ecuador), those with subjective cognitive complaints were referred to the Neuropsychology Outpatient Clinic for neuropsychological evaluation and to undergo complementary neuroimaging to achieve a differential diagnosis and establish appropriate treatment.\u003c/p\u003e\n\u003cp\u003eA semi-structured clinical interview and a self-report questionnaire were developed for this study to obtain a brief, clinically focused assessment of difficulties with\u0026nbsp;instrumental activities of daily living (IADLs)\u0026nbsp;(see supplementary Table 1).\u0026nbsp;\u0026nbsp;The individual clinical interview was conducted in a single session by the primary researcher, the neuropsychologist at the outpatient clinic. After the interview and obtaining informed consent, patient data were included in the study if the patients met the selection criteria as follows:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eInclusion criteria: being aged 60 years or older, having SCC, and signing the informed consent form.\u003c/p\u003e\n\u003cp\u003eExclusion criteria: patients with a prior diagnosis of advanced neurodegenerative disease and those with sensory limitations that precluded use of the instruments.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe control subjects were mostly relatives of the clinical participants and participants with sociodemographic characteristics similar to those of the clinical group.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eInstruments\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAccording to the most recent literature [21], a\u0026nbsp;neurocognitive testing protocol comprising seven tests was selected to assess various cognitive domains, with a primary focus on executive functions. An executive screening test such as the INECO frontal screening [29]; the Symbol Digit Modalities Test (SDMT) for attentional control [30]; the Verbal Fluency \u0026ndash; Animals subtest of the Seven-Minute Screen Neurocognitive Battery (CF-7MS) [31]; an episodic verbal memory test for immediate and delayed recall such as the Free and Cued Selective Reminding Test \u0026ndash; picture version (FCSRT) [32]; a test for planning and cognitive flexibility such as the Tower of London (ToL) [33]; and the Behavior Rating Inventory of Executive Function. Adult Version \u0026ndash; Spanish Version (BRIEF-A) as a questionnaire (self-report/informant) on the perception of present cognitive complaints [34]. Finally, self-report questionnaires were used to assess levels of depression and anxiety, using the Spanish version of the Beck Depression Inventory-Fast Screen (BDI-FS) [35,36] and the Spanish version of the Beck Anxiety Inventory (BAI) [37,38]. The reference scores for each test are shown in Table 1.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1. Normative references and interpretation criteria for the neuropsychological instruments used\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"591\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTEST [reference]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 114px;\"\u003e\n \u003cp\u003eProcess\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003eIndex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003eValues\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 43px;\"\u003e\n \u003cp\u003eSample\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 41px;\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003cp\u003e(years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 63px;\"\u003e\n \u003cp\u003eNationality\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eINECO\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eFrontal Screening (IFS)\u0026nbsp;\u003c/strong\u003e[39]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eExecutive functions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003eTotal score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003eCut-off score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u0026le; 23.5 suggests executive dysfunction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003e117\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 41px;\"\u003e\n \u003cp\u003e\u0026gt; 60\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003ePeruvian\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSDMT\u0026nbsp;\u003c/strong\u003e[40]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAttention/processing speed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTotal score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNorms\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(Mean \u0026plusmn; SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMean =34.9\u003c/p\u003e\n \u003cp\u003eSD = 10.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e316\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e65\u0026ndash;85\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHispanic\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCF-7MS\u0026nbsp;\u003c/strong\u003e[31]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eVerbal fluency (animals)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTotal score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNorms\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(Mean \u0026plusmn; SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMean = 19 \u0026nbsp; SD = 0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026gt; 65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eU.S.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFCSRT\u003c/strong\u003e [41]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eEpisodic memory\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eIFR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNorms\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(Mean \u0026plusmn; SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMean = 18.5\u003c/p\u003e\n \u003cp\u003eSD = 3.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;227\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e40\u0026ndash;94\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eItalian\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eITR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNorms\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(Mean \u0026plusmn; SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMean = 23.9; SD = 0.36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDFR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNorms\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(Mean \u0026plusmn; SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMean = 10.07 SD = 1.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDTR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNorms\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(Mean \u0026plusmn; SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMean = 11.97 SD = 0.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTower of London\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e[33]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePlanning / problem solving\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNumber of moves\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNorms\u003c/p\u003e\n \u003cp\u003e(SS)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eExpected average range: 31\u0026ndash;51 moves\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e347\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026gt; 60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eBritish\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTotal errors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNorms\u0026nbsp;\u003cbr\u003e\u0026nbsp;(SS)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eExpected average: \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; 0 errors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTotal initiation time\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNorms\u003c/p\u003e\n \u003cp\u003e(SS)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eExpected average range: 25\u0026ndash;63 seconds\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTotal execution time\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNorms\u003cbr\u003e\u0026nbsp;(SS)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eExpected average range: 361\u0026ndash;230 seconds\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTotal problem-solving time\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNorms\u003cbr\u003e\u0026nbsp;(SS)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eExpected average range: 415\u0026ndash;270 seconds\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eBRIEF-A\u0026nbsp;\u003c/strong\u003e[34]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eExecutive functions (ecological validity)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eTotal score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCut-off score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eT \u0026gt; 65 considered clinically significant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1,500\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e18\u0026ndash;90\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eU.S.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eBDI-SF\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(13 items)\u0026nbsp;\u003c/strong\u003e[36]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDepressive symptoms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTotal score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eClinical ranges\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u0026ndash;4 minimal; \u0026nbsp;5\u0026ndash;8 mild; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; 9\u0026ndash;13moderate;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u0026ge;14 moderate to severe\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026gt; 1,000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e16\u0026ndash;90\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eU.S.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eBAI\u0026nbsp;\u003c/strong\u003e[38]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAnxiety\u003c/p\u003e\n \u003cp\u003esymptoms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTotal score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eClinical ranges\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u0026ndash;7 minimal; \u0026nbsp; 8\u0026ndash;15 mild; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;16\u0026ndash;25 moderate; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;26\u0026ndash;63 severe\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e249\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e18\u0026ndash;78\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eU.S.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eNote.\u003c/strong\u003e Interpretation criteria were based on the normative studies and manuals specific to each instrument. Given the heterogeneity of scoring systems across neuropsychological measures (cut-off scores, normative data, standardized scores, and clinical ranges), interpretation followed the recommendations provided for each test rather than applying a single uniform criterion. SDMT: Symbol Digit Modalities Test; CF-7MS: Seven-Minute Seven Neurocognitive Battery; FCSRT- Free and Cued Selective Reminding; IFR: Immediate free recall; ITR: Immediate total recall; DFR: Delayed free recall; DTR: Delayed total recall; Test BRIEF-A: Behavior Rating Inventory of Executive Function. Adult Version; BDI-FS: Beck Depression Inventory-Fast Screen; BAI: Beck Anxiety Inventory; SS: Standard scores; SD: Standard Deviation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthical\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003eapproval and consent to participate\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Institutional review board (IRB) of the \u0026lsquo;Neuropsychology Outpatient Clinic\u0026rsquo; (October 1, 2020) and was conducted in accordance with the ethical standards of the Declaration of Helsinki.\u0026nbsp;All participants received a printed explanatory statement which included information about the study\u0026rsquo;s purpose, voluntary participation, potential risks, and confidentiality. Informed consent to use their data was obtained prior to participation. All responses were anonymised, and no personally identifying information was collected beyond general demographic characteristics. Data were stored on a password-protected, secure cloud server accessible only to the research team.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eData analysis\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe information was processed in Jasp 0.18.1.0, and the results are shown using measures of central tendency and dispersion. The data were normally distributed according to the Shapiro-Wilk test (p \u0026gt; 0.05), so the parametric Student\u0026apos;s \u003cem\u003et\u003c/em\u003e-test for independent samples was applied, and the effect size was determined using Cohen\u0026apos;s d. The reference points stipulated by each author were used to interpret each test. A minimum statistical significance of 5% (\u0026lt; 0.05) was considered.\u003c/p\u003e"},{"header":"3 Results","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e3.1. Semi-structured interview including functional difficulties\u003c/h2\u003e \u003cp\u003eA semi-structured interview including a brief, clinically oriented assessment of functional difficulties in IADLs (see Supplementary Table\u0026nbsp;1) was administered individually to patients referred to the Neuropsychology Outpatient Clinic, as part of a broader neuropsychological assessment.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e1.2. Participants\u003c/h2\u003e \u003cp\u003eThis study involved 40 adults aged 60 years or older, comprising 20 clinical participants with SCC and 20 control subjects. Each group included 10 women and 10 men, matched by sex and educational level. All participants were assessed at the Neuropsychological Outpatient Clinic of Santa In\u0026eacute;s Hospital in Cuenca, Ecuador.\u003c/p\u003e \u003cp\u003eThe mean age of the control group was 66.8 years (SD\u0026thinsp;=\u0026thinsp;4.0), while that of the clinical group was 71.8 years (SD\u0026thinsp;=\u0026thinsp;5.0). In terms of educational level, the two groups were similar: in the control group, 11 participants had completed secondary education and 8 had completed higher education; in the clinical group, 10 had completed secondary education and 9 had completed higher education, with 1 participant in each group reporting primary education. In terms of functionality, after a clinical interview, 8 participants in the clinical group had some functional limitations in instrumental activities of daily living (IADL).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e3.3. Neurocognitive testing\u003c/h2\u003e \u003cp\u003eIn accordance with the objectives set out, the results of each of them are described below, beginning with a presentation of the cognitive and emotional performance of the groups studied, the analysis of the perception of SCC according to the BRIEF-A, the findings of structural neuroimaging and complementary clinical diagnosis, and the proposed clinical protocol.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section3\"\u003e \u003ch2\u003e\u003cb\u003e3.3.1. Cognitive and emotional performance\u003c/b\u003e (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e)\u003c/h2\u003e \u003cp\u003e \u003cb\u003eCognitive performance\u003c/b\u003e \u003c/p\u003e \u003cp\u003e The executive performance of participants in the clinical group across several domains evaluated falls within the clinical percentile range, particularly in general executive performance (screening test), attentional control, verbal fluency, planning, cognitive flexibility, and memory recall.\u003c/p\u003e \u003cp\u003eWhen comparing the performance between the clinical group and the control group, significant differences were identified in practically all tests, with the most absolute (*** p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) being those in executive screening tests (INECO frontal screening-Total Executive Performance) and episodic verbal memory recall processes (IFR and IFD \u0026ndash; FCSRT). The second level of significance (** p\u0026thinsp;\u0026lt;\u0026thinsp;0.01) shows differences in variables related to overall execution speed and cognitive flexibility (Execution Time and Errors in the Tower of London). Thirdly, (* p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) there are differences in planning processes (Number of Moves \u0026ndash; London Tower), attentional control and processing speed (SDMT), immediate memory (ITR-FCSRT) and total delayed memory (DTR-FCSRT) (* p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Finally, there are no significant differences in performance on verbal fluency tests (CF-7MS), impulsivity control (starting time \u0026ndash; Tower of London), and working memory (INECO) between the groups studied.\u003c/p\u003e \u003cp\u003eIn the variable corresponding to qualitative errors (intrusions and perseverations) in the FCSRT test, only the clinical group presented this type of response (33 errors), whereas the control group did not (0 errors). This statistically significant difference ( *** p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) reflects a qualitatively different pattern of performance, rather than a simple quantitative variation in scores. The finding is clinically significant because it highlights a phenomenon present exclusively in the clinical group.\u003c/p\u003e \u003cp\u003e \u003cb\u003eEmotional performance\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe results for emotional aspects show no significant differences between the groups; furthermore, there are no clinically significant signs in either of the two areas evaluated; therefore, the sample shows no signs of anxiety-depressive symptoms that could interfere with their cognitive performance.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cb\u003eCognitive and emotional performance\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eDIMENSION of PERFORMANCE TEST / Process\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003cp\u003eMean (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePatient\u003c/p\u003e \u003cp\u003eMean (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003et\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eStatistics\u003c/p\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCohen's d\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eCOGNITIVE PERFORMANCE\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSDMT\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAttentional control/processing speed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33 (8.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26.8 (8.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.030*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.71\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eINECO\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExecutive performance (Total)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23.8 (2.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19.3 (3.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt; .001***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.42\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWorking memory\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.8 (1.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (1.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.098\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.54\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCF-7MS\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategorical evocation (animals)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.4 (4.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16.3 (4.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.140\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.48\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTower of London\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePlanning (Movements)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48.7 (22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e64.4 (26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-2.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.044*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-0.66\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eImpulsivity control (Start time/sec)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38.5 (15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e47.6 (18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-1.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.088\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-0.55\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOverall executive performance (Execution time/sec)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e280 (147)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e420 (223)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-2.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.024*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-0.74\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOverall executive performance (Total time/sec)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e318 (152)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e492 (203)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-3.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.004**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-0.97\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCognitive flexibility (Errors)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.1 (2.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.4 (5.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-3.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.003**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-1.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFCSRT\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIFR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.5 (1.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13 (3.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;..001***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.75\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eITR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23.9 (0.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22.8 (1.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt; .015*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.81\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDFR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.3 (1.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.8 (2.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt; .001***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.59\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDTR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.9 (0.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11 (1.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.021*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.76\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eQualitative errors \u003csup\u003eKW\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;. 001***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEMOTIONAL PERFORMANCE\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBDI-FS\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDepression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.1 (2.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.9 (4.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-1.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.106\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-0.52\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBAI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAnxiety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.1 (6.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11.6 (8.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-1.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.162\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-0.45\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e\u003cem\u003eNote: Group comparisons were performed using independent samples Student\u0026rsquo;s t-test (t), except for the variable of errors that was analyzed using non-parametric Kruskal-Wallis test (\u003c/em\u003e\u003csup\u003eKW\u003c/sup\u003e\u003cem\u003e) due to the data distribution of the control group. Statistical significance: *** p\u0026thinsp;\u0026lt;\u0026thinsp;0.001; ** p\u0026thinsp;\u0026lt;\u0026thinsp;0.01; *p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 difference.\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e\u003cb\u003e3.2. Perception of executive functioning\u003c/b\u003e (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e)\u003c/h2\u003e \u003cp\u003eAfter administering the self-report questionnaire and the informant report, concordance in the perception of executive deficits was assessed between the patient (self-report) and the family member (informant) for both the global and composite indices of executive functions and their respective dimensions. The only significant difference was observed in the Inhibition dimension, where family members reported greater difficulty in this aspect than the patient did (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eExecutive functioning (BRIEF A)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eTEST\u003c/b\u003e Cognitive process\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003ePatient\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eFamily\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e \u003cp\u003eStatistics\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eMean (SD)\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eCV (%)\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eMean (SD)\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eCV (%)\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003et\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003ep\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003eCohen's d\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBRIEF A (Indices and Global Executive)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGECT (Global Executive Composite)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e60.6 (10.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e59.8 (6.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.332\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.074\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBRIT (Behavior Regulation Index)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e59.4 (12.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e58.5 (8.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.359\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.080\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMIT (Metacognition Index)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e60.3 (8.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e60.0 (7.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.134\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.030\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBRIEF A (Dimensions)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInhibition\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e53.2 (9.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e58.1 (11.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e-2.378\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.03*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e-0.532\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFlexibility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e59.3 (11.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e59.9 (9.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e-0.163\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e-0.036\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmotional control\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e61.3 (13.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e57.8 (9.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.299\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.290\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSelf-control\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e55.1 (12.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e54.7 (9.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.199\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.044\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInitiative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e54.5 (10.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e56.7 (10.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e-0.693\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e-0.155\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWorking memory\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e67.5 (10.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e70.5 (6.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e-0.994\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e-0.222\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePlanning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e59.5 (9.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.163\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e55.4 (9.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.345\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.301\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOrganization\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e59.5 (9.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.163\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e55.4 (9.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.345\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.301\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTask tracking\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e58.3 (9.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.156\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e57.6 (7.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.136\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.201\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.045\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOrganization of materials\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e55.0 (11.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.206\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e57.7 (8.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.150\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e-0.947\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e-0.212\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e\u003cb\u003e3.3. Structural neuroimaging findings and clinical neurological diagnosis of the clinical group studied\u003c/b\u003e (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e)\u003c/h2\u003e \u003cp\u003eIt should be noted that, as part of the medical protocol for evaluating the clinical group, participants were referred for neuropsychological assessment and requested to undergo complementary neuroimaging tests. The aim was to ensure that subjects who initially reported SCC at their first medical appointment could receive an appropriate diagnosis and treatment.\u003c/p\u003e \u003cp\u003eAfter collecting medical information from the 20 subjects in the clinical group, it was determined that 14 (70%) showed significant findings on neuroimaging, including atrophy and cerebrovascular disease. Furthermore, after medical analysis of this information, supplemented by neuropsychological assessment, 16 participants (80%) met the diagnostic criteria for MCI (70%) and Alzheimer's disease (10%). These results support the clinical value of formal neuropsychological assessment within a multidisciplinary team.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eStructural neuroimaging, diagnosis, and treatment (clinical group)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eNeuroimaging\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eClinica Data\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWomen:Men ratio\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo data\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3:3\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBrain atrophy and cerebrovascular disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2:3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCerebral vascular disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2:3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBrain atrophy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3:1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDiagnosis\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDCL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7:5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo definite diagnosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1:2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDCL\u0026thinsp;+\u0026thinsp;depression/anxiety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1:1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAlzheimer's disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1:1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDCL\u0026thinsp;+\u0026thinsp;depression/anxiety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1:1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAnxiety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1:0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTreatment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTreatment - cognitive disorder\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5:5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTreatment - Anxiety/Depression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3:2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2:2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTreatment - cognitive disorder\u0026thinsp;+\u0026thinsp;anxiety/depression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0:1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10:10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e3.4. Proposed protocol\u003c/h2\u003e \u003cp\u003eBased on the results obtained and the absence of standardised protocols specifically guiding the clinical evaluation of these cases, it is considered necessary to propose its application in people with SCC, primarily to assess executive processes, given its possible predictive value in the preclinical stages of neurocognitive disorders. The protocol is based on a multidimensional model of executive functions, prioritising processes that have shown greater sensitivity to prodromal changes and that were assessed in our clinical study population.\u003c/p\u003e \u003cp\u003eA sequential, standardised, and flexible clinical protocol for the assessment of cognitive functioning is proposed, designed to explore in an integrated manner the interaction between executive functioning and other cognitive processes. A two-phase protocol is proposed:\u003c/p\u003e \u003cp\u003e \u003cb\u003ePhase 1. Anamnesis and screening\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThis includes an initial medical history (reason for consultation and characteristics of the subjective complaints), an executive screening test, a self-report/informant questionnaire on subjective complaints (with high ecological validity), and a questionnaire on anxiety-depressive symptoms. In this first phase, it is possible to identify areas that require specific evaluation or other factors that may be interfering with cognitive performance.\u003c/p\u003e \u003cp\u003e \u003cb\u003ePhase 2. Specific cognitive assessment\u003c/b\u003e \u003c/p\u003e \u003cp\u003eAn organized neuropsychological assessment containing a battery of tests in line with the objective of the assessment set out in phase 1 and based on relevant clinical criteria. It is suggested to start with an episodic memory test that incorporates visual stimuli (drawings), as this type of material is less dependent on language and educational level, thereby favoring its applicability across culturally diverse populations. The application of two initial learning trials is relevant for assessing coding ability, learning curve, and information retrieval strategies. Finally, after the interference interval, a delayed trial is applied.\u003c/p\u003e \u003cp\u003eThe interference interval consists of a stage in which associated cognitive processes are evaluated, including tests of categorical recall (lexical access and semantic organization), attentional control and processing speed, working memory, planning, and cognitive flexibility. Finally, the protocol concludes with the application of the delayed test (episodic memory), allowing evaluation of information consolidation, recall after interference, and determination of whether a possible memory deficit is due to failures in information retrieval or storage. An important element to consider is the presence or absence of dysfunctional clinical signs during neurocognitive task performance (intrusions, interference, and perseveration in episodic memory or categorical recall tests; errors in executive tasks; inhibitory errors; forgetting instructions, etc.).\u003c/p\u003e \u003cp\u003eBelow is a table outlining the cognitive domains and suggested tests/instruments that may be part of the clinical protocol (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). This selection is based on the existing literature on the tools most commonly used in studies of SCC and DCL [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e], as well as on studies that validate the tools used in this clinical study for patients with these characteristics [\u003cspan additionalcitationids=\"CR44 CR45 CR46 CR47 CR48 CR49 CR50 CR51\" citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eProposal of a Neuropsychological Care Protocol in SCC\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eNeuropsychological Care Protocol in Subjective Cognitive Complaints\u003c/span\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003ePhase 1. Anamnesis (semi-structured interview) and screening\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003ePhase 2. Specific cognitive and emotional assessment\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDomains\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eTests/instruments\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eProcess to be assessed\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eExecutive\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eFunctions\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTMT (A-B)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCognitive Flexibility\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStroop Test\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eInhibitory control and attention\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eToL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePlanning, working memory, and cognitive flexibility\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSemantic \u0026amp; Phonological Fluency\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eVerbal fluency as an executive measure\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eMemory\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRAVLT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eVerbal learning\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWMS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eImmediate and remote memory\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFCSRT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eConsolidation and recall processes (episodic memory)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eAttention / Processing\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003espeed\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDST\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWorking memory and attention\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSDMT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAttention and processing speed\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eScreening\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMMSE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCognitive screening\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIFS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExecutive screening\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eLanguage\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBNT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eVerbal naming\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSemantic Fluency\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSemantic access and language\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSelf-report/ informant report\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBRIEF A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQuestionnaire on perception of executive cognitive complaints\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eAnxiety/\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eDepression\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBDI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDepressive symptoms\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBAI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAnxiety symptoms\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFunctionality\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFAQ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eInstrumental functionality in daily activities\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eNote: TMT (A-B): Trail Making Test; ToL: Tower of London; RAVLT: Rey Auditory Verbal Learning Test; WMS: Wechsler Memory Scale; IFS: INECO frontal screening, FCSRT: Free Cued Selective Remaining Test; MMSE: Mini-Mental State Examination; DST: Digit Span Test; BNT: Digit Span Test; BRIEF-A: Behavior Rating Inventory of Executive Function. Adult Version; BDI: Beck Depression Inventory; BAI: Beck Anxiety Inventory; FAQ: Functional Activities Questionnaire.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe clinical criteria for diagnosis in the prodromal stages of possible neurodegenerative diseases continue to have considerable limitations. On the one hand, the conceptual shift in the terminology for cognitive complaints has enabled greater homogeneity in clinical evaluation criteria. The global, somewhat inconsistent view of the SCC construct has evolved toward more defined guidelines, such as SCD, which has operational criteria and is situated on the preclinical continuum of neurocognitive conditions, including Alzheimer's disease [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In this sense, a significant group of people with SCD is diagnosed with MCI when their cognitive decline is not sufficient for a diagnosis of dementia, and its etiology is multifactorial. However, not all patients with MCI progress to dementia or have established biological markers. For example, FCD is another clinical entity that can present with symptoms like MCI based on SCD; however, its etiology is not attributed to structural brain damage, it is usually reversible, and emotional factors also explain, in part, its progression. Improving the identification of SCD at its early stages, given the broad spectrum of underlying clinical and etiological conditions, would provide a better understanding of targeted early interventions [\u003cspan additionalcitationids=\"CR54\" citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCurrently, clinical research in the early stages of these conditions is beginning to focus more on cognitive processes beyond memory, as was previously the case, supporting the unquestionable contribution of a formal and detailed neuropsychological assessment in all primary care protocols [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e]. Several authors support focusing assessments on executive performance, where prodromal signs of neurodegenerative conditions appear, which would be of great clinical utility [\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e, \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn the present study on executive and emotional performance in people with subjective cognitive complaints, relevant information is provided on the characterisation of this population, and functional neurocognitive tests are identified for clinical application. According to the set objectives, the clinical group, which initially presented with SCC, showed overall executive deficits across the cognitive dimensions studied, with performance significantly worse than that of the control group.\u003c/p\u003e \u003cp\u003eThese data are corroborated by the literature, where several studies emphasise executive assessment in the preclinical stages of MCI and corroborate this possible relationship between executive deficits and progression to MCI and dementia [\u003cspan additionalcitationids=\"CR60 CR61 CR62 CR63 CR64 CR65 CR66 CR67\" citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e]. In this sense, executive deficits can be reflected in poor performance in processes such as decision-making, planning, cognitive flexibility, and processing speed [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e, \u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e], as well as in attentional control and working memory, which appear to be a cornerstone of these deficits in this population [\u003cspan additionalcitationids=\"CR72 CR73 CR74\" citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eResearch on cognitive performance in the prodromal stages of dementia remains inconsistent regarding the protocols to follow and the specific tools to use. The sole application of screening tools does not appear sufficiently viable or sensitive in the clinical context, even though some research shows the validity of tools such as the IFS for detecting early-onset cognitive impairment [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. In addition, certain reviews argue that, in addition to screening tests, studies should consider other specific tools to assess processes such as memory, language, and executive function [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e], as well as the use of self-report questionnaires/informant reports [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e]. In line with this, the present study followed this assessment route, which, using various tools, focused on executive processes without neglecting the evaluation of other cognitive domains, such as language (verbal fluency) and memory. In turn, although the scores on the self-report/informant questionnaire for subjective complaints did not reach clinical significance, the concordance between the reports confirms the need to include them in the clinical protocol.\u003c/p\u003e \u003cp\u003eFor its part, memory, a complex, multimodal cognitive construct that requires the activation of several brain circuits, has shifted from being assessed globally to being understood specifically through its dimensions. For example, beyond the importance of limbic circuits, the prefrontal cortex has been shown to contribute to several processes and dimensions, such as memory recall and working memory [\u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e78\u003c/span\u003e, \u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e]. The performance of our clinical group on episodic memory tests showed significantly lower recall processes compared to the control group, along with a higher number of pathological signs, such as intrusions, perseverations, and interferences.\u003c/p\u003e \u003cp\u003eDimensions such as memory recall and working memory have been linked to executive control, and studies have shown that patients with MCI and mild AD exhibit greater problems with recall processes and tools for information retrieval than with storage and consolidation [\u003cspan additionalcitationids=\"CR79\" citationid=\"CR78\" class=\"CitationRef\"\u003e78\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e]. The presence of intrusions and perseverations in this type of test also has significant predictive value in the preclinical stages of dementia [\u003cspan citationid=\"CR81\" class=\"CitationRef\"\u003e81\u003c/span\u003e, \u003cspan citationid=\"CR82\" class=\"CitationRef\"\u003e82\u003c/span\u003e]. Finally, the use of tests with visual elements (drawings), such as the one used in this study (FSCRT), has been shown to have greater validity due to its easy applicability to different populations without depending on factors such as language, culture, and educational level; it is also more accurate in discriminating between MCI and AD [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR83\" class=\"CitationRef\"\u003e83\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough the present study did not find significant signs of anxiety or depression, nor did it determine a direct relationship between cognitive performance and the presence of signs of anxiety and/or depression, several studies indicate that the presence of symptoms of anxiety and/or depression is associated with a higher probability of developing MCI and dementia. Likewise, there is a group of subjects whose cognitive performance may worsen due to these clinical symptoms, sometimes making it difficult to accurately diagnose the primary disorder [\u003cspan additionalcitationids=\"CR85\" citationid=\"CR84\" class=\"CitationRef\"\u003e84\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR86\" class=\"CitationRef\"\u003e86\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFurthermore, the literature has also supported a possible relationship between SCD, MCI, and the early stages of some dementias, with structural changes in specific brain regions. Lower executive performance would be associated with structural changes across cortical and subcortical areas, particularly in the frontal region [\u003cspan additionalcitationids=\"CR88 CR89\" citationid=\"CR87\" class=\"CitationRef\"\u003e87\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR90\" class=\"CitationRef\"\u003e90\u003c/span\u003e]. In the present study, a significant proportion of subjects showed structural changes on neuroimaging studies, which, although not conclusive, would support a possible relationship with low executive performance.\u003c/p\u003e \u003cp\u003eThe proposal for a clinical protocol in the present study is supported by the lack of consistency in the neuropsychological assessment methods used across multiple studies. Despite being considered a key component of any MCI care protocol, there remains a need for more uniform, evidence-based clinical guidelines grounded in longitudinal studies and clinical follow-up [\u003cspan citationid=\"CR91\" class=\"CitationRef\"\u003e91\u003c/span\u003e]. Cognitive semiology is also an essential element in its interpretation. Although normative scores provide relevant quantitative information, they do not reflect the complexity of cognitive functioning or the mechanisms underlying performance, which can be objectified through qualitative analysis [\u003cspan citationid=\"CR81\" class=\"CitationRef\"\u003e81\u003c/span\u003e, \u003cspan citationid=\"CR82\" class=\"CitationRef\"\u003e82\u003c/span\u003e, \u003cspan citationid=\"CR92\" class=\"CitationRef\"\u003e92\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFinally, regarding the limitations of the study, it should be noted that the results obtained in this research are from an outpatient clinical context and may therefore not be entirely generalizable to other contexts and/or populations. However, they do allow us to approximate the behavior of this clinical group as a guide to appropriate, early, timely intervention. The data on structural neuroimaging, diagnosis, and treatment should be followed up with a longitudinal study of this sample to provide greater precision on the objectives set and on their possible conversion to other clinical entities.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe poorer executive performance in the clinical group with subjective cognitive complaints empirically supports the conceptual reformulation proposed in recent literature, where complaints are no longer considered a nonspecific subjective phenomenon but are integrated into the concept of Subjective Cognitive Decline. This study suggests that self-perception of changes in cognitive performance could be associated with objectifiable executive alterations, supporting its predictive and clinical value.\u003c/p\u003e \u003cp\u003eAccording to the results, the clinical group showed poor overall cognitive performance, with most scores falling within clinically indicative ranges. There were significant differences from the control group in domains such as overall executive performance, attentional control, memory recall, planning, cognitive flexibility, and processing speed, as well as in the presence of qualitative errors, such as intrusions and perseverations. Emotional performance showed an absence of anxiety-depressive symptoms, with no significant differences between the clinical group and the control group.\u003c/p\u003e \u003cp\u003eThere was agreement between the clinical group's perception of the executive deficits present (self-report) and the perception of a family member (informant), with a significant difference in the dimension of inhibition, where family members perceive greater difficulties.\u003c/p\u003e \u003cp\u003eThe results of structural neuroimaging and complementary clinical diagnosis determined that most of the clinical group showed clinically significant data, such as signs of atrophy and cerebrovascular disease, after which they were diagnosed with MCI and/or Alzheimer's disease.\u003c/p\u003e \u003cp\u003eA proposal for a clinical protocol is presented, outlined, and applicable to the clinical setting, focusing mainly on the assessment of executive processes, along with other important cognitive domains such as memory and language. A flexible protocol that also includes self-report questionnaires and informant reports on anxiety-depression symptoms and functionality.\u003c/p\u003e \u003cp\u003eFinally, future research needs to delve deeper into other variables that may interfere with the relationship between SCD and its possible predictive value for the development of neurodegenerative conditions, carry out longitudinal and follow-up designs, as well as correlational studies with biomarkers that allow more specific parameters to be established, thus guiding more appropriate intervention in this population.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eFunding: The present work was performed without funding.\u003c/p\u003e\n\u003cp\u003eEthics approval and consent to participate: All participants provided written informed consent prior to inclusion in the study.\u003c/p\u003e\n\u003cp\u003eConsent for publication: Not applicable.\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials: The datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003eCompeting interests: The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003eAuthors’ contributions: Conceptualization, F.W.-C. and L.G.-L.; methodology, F.W.-C.; writing—original draft preparation, F.W.-C.; writing—review and editing, F.W.-C. and L.G.-L.; supervision, L.G.-L. All authors have read and agreed to the published version of the manuscript.\u003c/p\u003e\n\u003cp\u003eAcknowledgements: To the participants and the Neuroimaging Service at Hospital Santa Inés, Cuenca, Ecuador.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eChen R, Zou J, Chen J, Wang L, Kang R, Tang D. Immune aging and infectious diseases. Chin Med J (Engl). \u003cstrong\u003e2024\u003c/strong\u003e;137(24):3010-3049. doi:10.1097/CM9.0000000000003410.\u003c/li\u003e\n \u003cli\u003eHao, M., Chen, J. Trend analysis and future predictions of global burden of alzheimer\u0026rsquo;s disease and other dementias: a study based on the global burden of disease database from 1990 to 2021.BMC Med. \u003cstrong\u003e2025\u003c/strong\u003e;23(378). https://doi.org/10.1186/s12916-025-04169-w.\u003c/li\u003e\n \u003cli\u003e\u003cem\u003eWorld Health Organization. Dementia(Internet). 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New York: Basic Books; 1980.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-neurology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurl","sideBox":"Learn more about [BMC Neurology](http://bmcneurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurl","title":"BMC Neurology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Subjective cognitive complaints, Dementia, Executive performance, Neuropsychological assessment, self- and informant report","lastPublishedDoi":"10.21203/rs.3.rs-9059640/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9059640/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThe presence of subjective cognitive complaints (SCC) in older adults, especially at the executive level, is a major reason for consultation in clinical practice. These changes, though often subtle, may result from various factors but could also signal underlying neurocognitive conditions, making early detection and intervention crucial. This study aimed to assess executive and emotional performance, to assess both the subject\u0026rsquo;s and the informant\u0026rsquo;s perceptions of cognitive complaints, and to develop a clinical care protocol for individuals attending neuropsychological consultations due to SCC. Seven neuropsychological tests (FSCRT, SDMT, INECO Frontal Screening, CF-7MS, Tower of London, BRIEF-A, Beck tests) were administered to 40 older adults: 20 clinical subjects (mean age: 71.8\u0026thinsp;\u0026plusmn;\u0026thinsp;5.0) and 20 controls (mean age: 66.8\u0026thinsp;\u0026plusmn;\u0026thinsp;4.0), including both sexes. Results showed a significant difference in overall executive performance between the clinical and control groups across sustained attention, memory recall, planning, cognitive flexibility, and processing speed, with the clinical group performing worse and, most importanly, exhibiting clinically significant scores. In comparing the subject\u0026rsquo;s and informant\u0026rsquo;s reports of cognitive complaints, agreement was found in all dimensions except Inhibition, where a notable discrepancy emerged: informants reported worse performance. No differences in emotion were observed between groups. Based on these findings, a clinical protocol centered on executive assessment is proposed, encompassing multiple cognitive domains, emotional questionnaires, self- and informant-reported complaints, functioning, and clinical-cognitive semiology. In conclusion, executive deficits may be present in patients with SCC, and executive assessment is a valuable tool for detecting possible prodromal neurocognitive changes. Implementing systematized protocols in clinical neuropsychological practice can strengthen primary health care, though future research should aim for a more established consensus.\u003c/p\u003e","manuscriptTitle":"Executive impairment and informant-reported inhibition discrepancy in subjective cognitive complaints: comparative findings and neuropsychological care protocol proposal","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-23 10:34:10","doi":"10.21203/rs.3.rs-9059640/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-05-11T16:15:12+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-07T17:22:33+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-30T06:15:44+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"255647401653014140969252582977989669963","date":"2026-04-27T15:06:20+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-27T02:53:30+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-23T19:44:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"16567890987651725690133609442238874520","date":"2026-04-22T18:22:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"323701225292540962132728494786979594990","date":"2026-04-16T08:09:03+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"208533460710567207615512947972917308256","date":"2026-04-15T16:52:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"253711331744822351128028199813109864155","date":"2026-04-15T13:20:36+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-15T12:22:55+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-13T10:11:28+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-25T15:43:43+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-24T19:06:44+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Neurology","date":"2026-03-24T19:02:22+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-neurology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurl","sideBox":"Learn more about [BMC Neurology](http://bmcneurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurl","title":"BMC Neurology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"98452377-c9d2-4ee6-927c-fa3d7ca4186a","owner":[],"postedDate":"April 23rd, 2026","published":true,"recentEditorialEvents":[{"type":"decision","content":"Revision requested","date":"2026-05-11T16:15:12+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-07T17:22:33+00:00","index":82,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-30T06:15:44+00:00","index":81,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-05-11T16:25:51+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-23 10:34:10","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9059640","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9059640","identity":"rs-9059640","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}