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ABSTRACT
Background: The goals of this study were to establish prevalence of subjective memory complaints (SMC) and
depressive symptoms (DS) and their relation to cognitive functioning and cognitive status in an outpatient
memory clinic cohort.
Methods: Two hundred forty-eight cognitively healthy controls and 581 consecutive patients with cognitive
complaints who fulfilled the inclusion criteria were included in the study.
Results: A statistically significant difference (p < 0.001) between control group and patient group regarding
mean SMC was detected. 7.7% of controls reported a considerable degree of SMC, whereas 35.8% of patients
reported considerable SMC. Additionally, a statistically significant difference (p < 0.001) between controls
and patient group regarding Beck depression score was detected. 16.6% of controls showed a clinical relevant
degree of DS, whereas 48.5% of patients showed DS. An analysis of variance revealed a statistically significant
difference across all four groups (control group, SCI group, naMCI group, aMCI group) (p < 0.001). Whereas
8% of controls reported a considerable degree of SMC, 34% of the SCI group, 31% of the naMCI group,
and 54% of the aMCI group reported considerable SMC. A two-factor analysis of variance with the factors
cognitive status (controls, SCI group, naMCI group, aMCI group) and depressive status (depressed vs. not
depressed) and SMC as dependent variable revealed that both factors were significant (p < 0.001), whereas
the interaction was not (p = 0.820).
Conclusions: A large proportion of patients seeking help in a memory outpatient clinic report considerable
SMC, with an increasing degree from cognitively healthy elderly to aMCI. Depressive status increases SMC
consistently across groups with different cognitive status.
Key words: subjective memory impairment, mild cognitive impairment subtypes, neuropsychological testing
Introduction
Subjective memory complaints (SMC) are common
in older people and clinicians often rely heavily
on such complaints when deciding whether or
not to take action/treatment. SMC may be an
early symptom of dementia in those with normal
cognition, and may be useful to clinicians in
predicting development of dementia (Abdulrab and
Heun, 2008).
Subjective cognitive impairment (SCI), usually
defined by subjective reports of memory worsening
and cognitive performance in the normal adjusted
range (Stewart, 2012), are increasingly a focus in
studies on prodromal Alzheimer disease (AD) and
Correspondence should be addressed to: PD. Dr. Johann Lehrner, Department
of Neurology, Medical University of Vienna, Whringer Grtel 18-20,
1097 Vienna, Austria. Phone: 0043-1-40400-3109; Fax: 0043-1-40400-3141.
Email: johann.lehrner@meduniwien.ac.at. Received 8 Aug 2013; revision
requested 29 Aug 2013; revised version received 23 Sep 2013; accepted 4
Nov 2013.
J. Lehrner et al.
Methods
Subjects and procedure
The current data are part of a larger research
project, the Vienna Conversion to Dementia Study
(VCD-Study). The VCD is a prospective cohort
study encompassing consecutive, communitydwelling patients complaining of cognitive problems
who come to the memory outpatient clinic for
assessment of a possible cognitive disorder. The
study protocol has been approved by the Ethical
Committee of the Medical University of Vienna and
written informed patient consent to perform this
study has been received.
All patients received a complete neurological
examination, standard laboratory blood tests
and psychometric testing. In most cases, a
Measures
Assessment of subjective memory complaint
For the assessment of subjective memory complaint,
the Forgetfulness Assessment Inventory (FAI) scale
was used. The FAI was developed to evaluate
subjective complaints regarding everyday memory
problems (Kogler, 2013). The questions were
selected to focus on the subjective evaluation
of memory problems, particularly in relation to
episodic memory which has been found to be very
sensitive in the early detection of MCI and AD.
It is a 16-item instrument to measure subjective
memory problems in daily life scored on the basis
of a Likert scale. Subjects were asked, e.g. How
often did you have problems during the past 4
weeks remembering . . . .. e.g. a shopping list.
1 = never; 2 = rarely, 3 = sometimes, 4 often,
5 very often. See Table 2 for specific items. The
average score across all 16 items was used for
statistical analyses. Higher scores reflect poorer
subjective functioning and greater complaints
(possible range: 15). Raw scores were also
transformed into z-scores using a normative sample
and the flexible GAMLSS (Generalized Additive
Models for Location, Scale and Shape) model
J. Lehrner et al.
Table 1. Neuropsychological test scores (single tests z-scores as well as domain test z-scores and total z-score)
across Control group, SCI group, naMCI group, and aMCI group
CONTROL
SCI
naMCI
aMCI
...........................................................................................................................................................................................................................................................................................................................
AKT time
AKT total/time
Trail-Making Test TMTB
Digit-Symbol Test (WAIS-R)
TMTB TMTA difference
Symbols counting (C.I.)
Phonematic verbal fluency PWT total words
Phonematic verbal fluency PWT l-words
Phonematic verbal fluency PWT f-words
Phonematic verbal fluency PWT b-words
Stroop color words
Stroop total/time
Interference (C.I.) time
Interference (C.I.) total/time
Stroop color words - colors
Stroop colors
Semantic verbal fluency SWT total words
Semantic verbal fluency SWT supermarket items
Semantic verbal fluency SWT animals
Semantic verbal fluency SWT tools
Boston Naming Test (mBNT)
Verbal memory total recall (VSRT)
Verbal memory immediate recall (VSRT)
Verbal memory delayed recall (VSRT)
Verbal memory recognition (VSRT)
Planning Maze test NAI time
Planning Maze test NAI total/time
Nonverbal Fluency FivePoint Test total correct
Trail-Making Test TMTA
Nonverbal Fluency Five-Point Test perseverations
Domain 1 attention
Domain 2 executive function phonemic verbal fluency
Domain 3 executive function - interference
Domain 4 language
Domain 5 memory
Domain 6 executive function- planning and nonverbal fluency
Total z-scores
0.08 1.1
0.07 1.0
0.08 1.1
0.07 1.0
0.10 1.2
0.01 0.9
0.24 1.1
0.18 1.0
0.23 1.2
0.21 1.1
0.05 1.0
0.06 1.0
0.06 1.0
0.02 1.0
0.08 1.1
0.06 1.0
0.33 1.0
0.33 1.1
0.34 1.3
0.23 1.1
0.55 0.6
0.20 1.0
0.19 1.0
0.12 1.0
0.64 0.6
0.00 1.0
0.01 1.0
0.00 1.0
0.01 0.9
0.35 0.8
0.04 0.8
0.21 1.0
0.05 0.9
0.25 0.9
0.04 0.8
0.02 0.9
0.04 0.5
0.32 1.0
0.29 0.9
0.12 1.1
0.09 0.9
0.25 1.2
0.66 1.0
0.14 1.0
0.17 0.9
0.18 1.1
0.05 1.0
0.17 1.0
0.16 1.1
0.29 0.9
0.29 1.0
0.09 1.7
0.50 1.1
0.26 0.9
0.26 1.1
0.21 1.2
0.20 0.8
0.81 0.7
0.01 0.8
0.07 0.9
0.14 0.9
0.70 0.7
0.39 1.0
0.37 1.0
0.17 1.1
0.18 1.0
0.58 1.0
0.16 0.7
0.14 0.8
0.24 0.8
0.17 0.8
0.17 0.7
0.34 0.8
0.09 0.4
0.70 1.3
0.74 1.3
1.49 1.3
0.74 0.8
1.60 1.7
0.17 1.2
1.73 1.4
1.24 1.4
1.21 0.8
1.60 1.3
1.02 1.2
0.92 1.0
0.80 1.1
0.85 1.2
0.80 1.6
0.55 1.2
1.04 1.3
0.77 1.0
1.12 1.7
0.55 1.0
1.10 1.0
0.57 0.8
0.46 0.9
0.60 0.9
0.76 0.7
0.78 1.4
0.70 1.2
0.94 1.2
0.68 1.0
0.39 0.8
0.91 0.9
1.46 1.1
0.83 0.9
0.89 1.0
0.58 0.6
0.79 1.0
0.89 0.4
0.47 1.30
0.53 1.29
1.19 1.62
0.69 1.21
1.22 1.78
0.19 1.32
0.91 1.62
0.60 1.63
0.61 1.30
0.89 1.48
0.86 1.33
0.81 1.21
0.43 1.38
0.46 1.49
0.78 1.63
0.25 1.37
0.97 1.22
0.77 1.05
1.06 1.75
0.44 0.94
1.00 0.93
2.17 0.94
1.68 0.72
2.56 1.01
1.96 1.02
0.41 1.67
0.26 1.46
0.80 1.31
0.48 1.36
0.46 0.89
0.71 1.13
0.76 1.34
0.61 1.16
0.83 0.98
2.10 0.50
0.47 1.30
0.86 0.73
AKT = Alters-Konzentrations-Test; WAIS-R = Wechsler Adult Intelligence Scale - Revised; TMTA = Trail Making Test Version A;
TMTB = Trail Making Test Version B; NAI = Nrnberger Alters Inventar; C.I. = Cerebral Insufficiency Test; VSRT = Verbal Selective
Reminding Test; mBNT = modified Boston Naming Test.
Statistical Methods
Demographic variables are described by means
and standard deviations except MMSE scores and
BDI-II scores, which are presented as median
and quartiles due to the skewed distribution of
these variables. FAI scores and z-scores of the
neuropsychological test variables are described by
means and standard deviations.
In order to compare dependent variables
between groups, t-tests and one-way ANOVAs have
been computed. Uncorrected p-values are given.
Post-hoc pairwise comparisons have been adjusted
using Tukeys method. Spearman correlational
analyses were also performed.
RARELY
SOMETIMES
OFTEN
VERY OFTEN
...........................................................................................................................................................................................................................................................................................................................
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
...
...
...
...
...
...
...
...
...
...
...
...
...
...
...
...
Names of people?
Telephone numbers?
Faces?
Birthdays?
Poems?
Book titles?
Content of television broadcasts?
Shopping lists?
Directions?
Discussion topics?
Content of radio broadcasts?
Content of news broadcasts?
Arrangements?
Prices of bread and milk?
Numbers?
Lyrics?
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
Here are a few questions regarding your memory. Please answer each question by selecting the appropriate digit (1,2,3 . . . .). If you are not
sure how to answer the question, give your best possible answer and make a remark on the left side of the page. Please do not hesitate to ask
for support if you need help reading or filling in the questionnaire. How often did you have problems during the past 4 weeks
remembering . . .
The reported p-values are the result of twosided tests. p-values 0.05 were considered
to be statistically significant. All computations
were performed using SAS software Version 9.2
(SAS Institute Inc., Cary, NC, USA, 20022008),
except GAMLSS estimation, which was done using
R 2.11.1.
Results
A statistically significant difference (p < 0.001)
between control group and patient group (2.33
0.65 vs. 2.93 0.77) regarding mean FAI score
was detected. Furthermore, a statistically significant
difference (p < 0.001) between control group and
total patient group (0.03 1.01 vs. 1.01
1.34) regarding mean FAI z-score was detected.
The frequency (prevalence) of controls and patients
indicating subjective memory complaint (defined as
complaining at least 1.5 SDs below of the age,
sex, and schooling specific mean of the normative
sample) are also reported. Ninteen controls out of
247 (7.7%) reported a considerable degree of SMC,
whereas 208 patients out of 581(35.8%) reported a
considerable degree of SMC.
Statistical analysis detected a significant difference (p < 0.001) between the control group and
patient group (5; quartiles 29 vs. 10; quartiles 6
15) regarding the median Beck depression score.
The frequency (prevalence) of patients and controls
having DS (defined as having a BDI score >10) are
also reported. Forty-one controls (16.6%) out of
247 showed DS, whereas 282 patients (48.5%) out
581 showed DS.
J. Lehrner et al.
Table 3. Spearman correlation coefcients (r) for the patient group between FAI
z-score and MMSE, BDI-II score and neuropsychological test scores (single tests
z-scores as well as domain test z-scores and total z-score)
SMC Z-SCORE
....................................................................................................................................................................................................................................
MMSE
BDI-II
Domain 1 attention
AKT time
AKT total/time
Trail-Making Test TMTB
Digit-Symbol Test (WAIS-R)
TMTB TMTA difference
Symbols counting (C.I.)
Domain 2 executive function phonemic verbal fluency
Phonematic verbal fluency PWT total words
Phonematic verbal fluency PWT l-words
Phonematic verbal fluency PWT f-words
Phonematic verbal fluency PWT b-words
Domain 3 executive function - interference
Stroop color words
Stroop total/time
Interference (C.I.) time
Interference (C.I.) total/time
Stroop color words colors
Stroop colors
Domain 4 language
Semantic verbal fluency SWT total words
Semantic verbal fluency SWT supermarket items
Semantic verbal fluency SWT animals
Semantic verbal fluency SWT tools
Boston Naming Test (mBNT)
Domain 5 memory
Verbal memory total recall (VSRT)
Verbal memory immediate recall (VSRT)
Verbal memory delayed recall (VSRT)
Verbal memory recognition (VSRT)
Domain 6 executive function planning and nonverbal fluency
Planning Maze Test NAI time
Planning Maze Test NAI total/time
Nonverbal Fluency Five-Point Test total correct
Trail-Making Test TMTA
Nonverbal Fluency Five-Point Test perseverations
Total z-scores
0.06
0.29
0.00
0.00
0.02
0.02
0.08
0.00
0.01
0.01
0.02
0.01
0.02
0.02
0.11
0.08
0.06
0.04
0.04
0.04
0.08
0.04
0.02
0.02
0.00
0.04
0.06
0.09
0.14
0.10
0.12
0.06
0.05
0.04
0.02
0.03
0.08
0.02
0.03
70
66.42%
63.66%
60
54.32%
50
45.68%
40
33.61%
30.60%
30
20
10
7.69%
6.88%
2.99%
2.73%
0.00%
0
<= -1.5
med
Control
>= +1.5
<= -1.5
med
>= +1.5
SCI
<= -1.5
med
Non-amn.MCI
>= +1.5
<= -1.5
med
Amn. MCI
>= +1.5
FAI
'
Figure 1. Distribution of the frequency of patients reporting subjective memory complaint (FAI) (dened as age, sex, and schooling specic
z-score below or equal to 1.5) across groups (controls, SCI group, a naMCI group, aMCI group).
the difference in FAI between depressed and nondepressed is not significantly different between the
four cognitive groups. Post-hoc analyses revealed
significant pairwise differences between all groups
except for SCI versus naMCI (p = 0.78). See
Figure 3 for details.
Discussion
In the present study, we investigated SMC and
DS and their relationship to cognitive functioning
and cognitive status in patients attending a memory
disorder outpatient clinic. We found that patients
reported significantly more SMC than a cognitively
healthy, age-matched control group. Whereas 7% of
controls showed elevated SMC, 36% of the patients
reported elevated SMC. Although, prevalence of
SMC is dependent on several factors including
setting and methodology, our finding is in line with
recent work. For instance, in a study of 758 older
people attending Primary Care, 24% reported SMC
(Waldorff et al., 2012). A different finding was
obtained for DS. Whereas 16% of controls showed
clinical relevant DS, roughly half of the patients
(48%) showed DS. This result is in line with
J. Lehrner et al.
50
40
30
20
10
0
Con trol
SC I
No n-am n.MC I
Am n. MCI
Figure 2. (Colour online) Depressive symptoms across groups (controls, SCI group, a naMCI group, aMCI group): boxplots.
z-FAI
-1
-2
-3
-4
Control
SM
BDI
Non-amn. MCI
normal
Amn.MCI
depressed
Figure 3. Subjective memory complaint (FAI) and its relation to depressive status and cognitive status (controls, SCI group, a naMCI group,
aMCI group): error bars show mean 1 standard deviation.
Acknowledgment
The authors thank Arinya Eller for proofreading this
manuscript.
10
J. Lehrner et al.
References
Abdulrab, K. and Heun, R. (2008). Subjective Memory
Impairment. A review of its definitions indicates the need
for a comprehensive set of standardised and validated
criteria. European Psychiatry, 23, 321330. doi:
10.1016/j.eurpsy.2008.02.004.
Albert, M. S. et al. (2011). The diagnosis of mild cognitive
impairment due to Alzheimers disease: recommendations
from the National Institute on Aging-Alzheimers
Association workgroups on diagnostic guidelines for
Alzheimers disease. Alzheimers Dement, 7, 270279. doi:
S1552-5260(11)00104-X [pii]10.1016/j.jalz.2011.03.
008.
Clement, F., Belleville, S. and Gauthier, S. (2008).
Cognitive complaint in mild cognitive impairment and
Alzheimers disease. Journal of the International
Neuropsychological Society, 14, 222232. doi:
10.1017/s1355617708080260.
Dilling, H., Mombour, W. and Schmidt, M. H. (Eds.).
(2000). Internationale Klassifikation Psychischer Strungen.
ICD-10 Kapitel V (F). Klinisch -diagnostische Leitlinien, 4th
edn. Bern: Huber.
Erk, S., Spottke, A., Meisen, A., Wagner, M., Walter, H.
and Jessen, F. (2011). Evidence of neuronal
compensation during episodic memory in subjective
memory impairment. Archives of General Psychiatry, 68,
845852.
Gatterer, G. (2008). Alters-Konzentrations-Test (AKT) (2.,
neu normierte Auflage ed.). Gttingen: Hogrefe.
Goodglass, H. and Kaplan, H. (1983). The Assessment of
Aphasia and Related Disorders, 2nd ed. Philadelphia: Lea &
Fabinger.
Hautzinger, M., Keller, F. and Khner, C. (2006). Beck
Depressions-Inventar (BDI-II), revised edn. Frankfurt:
Harcourt.
Ivnik, R. et al. (1992). Mayo`s older Americans normative
studies: WAIS-R, WMS-R and AVLT norms for ages 56
through 97. Clinical Neuropsychology, 6, 1
104.
Jessen, F. et al. (2007). Patterns of subjective memory
impairment in the elderly: association with memory
performance. Psychological Medicine, 37, 17531762. doi:
10.1017/s0033291707001122.
Jessen, F. et al. (2010). Prediction of dementia by subjective
memory impairment effects of severity and temporal
association with cognitive impairment. Archives of General
Psychiatry, 67, 414422.
Jungwirth, S., Fischer, P., Weissgram, S., Kirchmeyr,
W., Bauer, P. and Tragl, K. H. (2004). Subjective
memory complaints and objective memory impairment in
the Vienna-Transdanube aging community. Journal of the
American Geriatrics Society, 52, 263268. doi:
10.1111/j.1532-5415.2004.52066.x.
Kogler, B. (2013). Subjective Memory Complaint in Mild
Cognitive Impairment, Alzheimers Disease and Parkinsons
Disease. Vienna: University of Vienna.
Lam, L. C. W., Lui, V. W. C., Tam, C. W. C. and Chiu,
H. R. K. (2005). Subjective memory complaints in
Chinese subjects with mild cognitive impairment and early
Alzheimers disease. International Journal of Geriatric
Psychiatry, 20, 876882. doi: 10.1002/gps.1370.
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