Organizational closure through regenerative signaling as a possible basis for conscious awareness.

The number of older adults globally is projected to rise by 22% by 2050 (). Asia’s share of the older adult population is expected to rise from 56.7 to 61.5% between 2020 and 2060 (), with the proportion of older adults in India expected to double by 2050 (). This demographic shift underscores the crucial importance of understanding age-related health issues, particularly those affecting cognitive function. According to the National Institute on Ageing and Alzheimer’s Association (NIA-AA), the syndromal cognitive staging scheme categorizes the cognitive continuum into three categories namely Cognitively Unimpaired (CU), Mild Cognitive Impairment, and Dementia (further divided into mild, moderate, severe) (). CU, often referred to as cognitively normal, implies cognitive performance within expected range for the individual based on available information. MCI implies cognitive performance below expected range for that individual based on all available information. The basis of both CU and MCI could be clinical judgment and/or cognitive test performance, which may involve comparison to normative data, adjustments for age, sex, etc. Dementia involves substantial progressive cognitive impairment that affects several domains and/or neurobehavioral symptoms. The symptoms may be recognized by the individual, the observer, or the observed in longitudinal cognitive testing. Cognitive impairment (MCI or dementia) is known to impact an individual’s health, overall quality of life, and survival, often leading to higher rates of disability among older adults (). Nationally representative studies claim approximately 8.8 million (7.4%) older Indian adults live with dementia, with cases unevenly distributed across states and place of residence (). Despite this significant burden, only a limited number of empirical, population-based studies have investigated cognitive function and its multifaceted associations with demographic, socioeconomic, health, and behavioral factors, especially in low-resource setting (; ). One important barrier is the availability of culturally appropriate and linguistically adapted neuropsychological tests with robust normative data (). Normative data are observational, empirical, statistical data summarizing what is usual (or typical) in a defined population, culture, institution, or health care system at a specific point or period of time, and describe observed phenomena or characteristics (). Selecting appropriate normative data affects the accuracy of neuropsychological assessment findings, which may further reduce false diagnoses of cognitive decline (). The Indian population is heterogeneous not only in terms of language and religion but also in a myriad of cultural and socioeconomic factors that may confound performance on neuropsychological tests (; ; ). Cognitive testing is particularly challenging in rural areas where formal education, healthcare access, and validated normative benchmarks are lacking, leading to delayed diagnosis and an increased risk of misclassification when normative values validated for urban or literate populations are applied (; ). The literature reports that older adults living in rural areas have significantly lower cognitive performance than those living in urban communities (; ; ). The considerable sociocultural and demographic heterogeneity of the Indian population highlights the need for culturally appropriate cognitive assessment tools and language-specific normative data, particularly for those who remain under-represented in neuropsychological research. Cognitive assessment tools available in Indian context include NIMHANS Neuropsychological Battery for Elderly (NNB-E), Addenbrooke’s Cognitive Examination-III (ACE III) (; ), the Consortium to Establish a Registry for Alzheimer’s Disease-Neuropsychological Battery (CERAD-NB) (), the Kolkata screening battery (KS) (), and the PGI battery of brain dysfunction (PGI-BBD) (), Computerized assessment of adult information processing (COGNITO), and the Indian Council of Medical Research-Neurocognitive Tool Box (ICMR-NCTB) (; ) battery. ICMR-NCTB was developed upon reviewing existing Indian and international batteries (including ACE-III, CERAD, NIMHANS, Kolkata Screening Battery, PGI-BBD, etc.) and selecting culturally adaptable tests across Indian languages. NNB-E is considered the closest to ICMR-NCTB, however, NCTB adds multilingual standardization and harmonized multi-domain assessment protocol across India validated for education levels and multiple languages including Hindi, Bengali, and Kannada making it more generalizable. Thus, determining expected cognitive functioning using the ICMR-NCTB battery and establishing population-specific normative data (for comparison with individuals suspected of dementia) is the need of the hour for the rural older-adults (; ).