The “biological view” of Alzheimer's disease (AD) focuses on the role of plaques and tangles and excludes syndromes from the disease definition. However, cognitive syndromes are fundamental aspects of AD and are the ultimate target of treatments. Accordingly, the study of cognitive syndromes should remain a major goal of AD research. We questioned how well the idea of excluding cognitive syndromes from the definition of AD is scientifically supported. In this regard, we believe that the “biological view” of AD is sustainable if a close relationship between plaques and tangles and cognitive disorders is discovered. A simple way to preliminarily investigate the strength of this relationship is to test whether the study of plaques and tangles allows us to make predictions about the characteristics of cognitive impairment. For this purpose, we summarized the main data from the literature on the predictions that can be made about cognitive impairment from the study of plaques and tangles in AD. The results showed that although plaques precede cognitive symptoms, most people with plaques do not develop cognitive deficits, and the association between plaque distribution and clinical features is weak. Tangles have a stronger association with the presence and severity of cognitive decline, but this is because tau protein involvement is a more terminal event, occurring as a result of neuronal loss. Overall, the predictions that can be made about the main features of the cognitive picture from the study of plaques and tangles still appear limited and imprecise.
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