INTRODUCTION The mechanism linking amyloid beta (A beta) pathology to cognitive decline in pre-dementia stages remains unclear.METHODS We performed mediation analysis in 223 non-demented adults (4-year follow-up) to assess plasma glial fibrillary acidic protein (GFAP), phosphorylated tau (p-tau)181, p-tau217, and peripheral inflammatory ratios as mediators of A beta (18F-florbetapir positron emission tomography)-related cognitive decline and hippocampal atrophy.RESULTS Plasma GFAP significantly mediated A beta-related multi-domain cognitive decline (accounting for 17.70% to 23.77% of the total effect) and hippocampal atrophy (specifically in the subgroup aged <= 70 years). Although both p-tau181 and p-tau217 were correlated with cognitive decline, they did not function as significant mediators of A beta's effects. Peripheral inflammatory ratios demonstrated no significant association with Alzheimer's disease (AD) progression.DISCUSSION Plasma GFAP is a key mediator and promising early biomarker for pre-dementia AD.