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There is an increasing move towards attempting to detect Alzheimer's disease at the very earliest stages, not just in the mild dementia phase or the mild cognitive impairment phase, but even in the preclinical phase. This raises a number of challenges for neuropsychological assessment, in trying to detect subtle but clinically significant cognitive impairment, differentiate neuropathological from normal aging, and aid prognosis by accurately identifying those who will progress and transition to dementia from those who will not. A variety of demographic and psychometric factors contribute to variability in test performance and raise important questions not just about how we define normality and abnormality but also about the limitations of our current assessment methods. Accelerated long-term forgetting is identified as a particular challenge as its prevalence is unknown and virtually all of our current standardized assessment methods would fail to detect it.