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Learning and Recall in Subjects at Genetic Risk for Alzheimer’s Disease

J. Gene Chen, B.S. Christopher L. Edwards, Ph.D. Suman Vidyarthi, B.S. Suresh Pitchumoni, B.S. Sara Tabrizi, B.S. Dan Barboriak, M.D. H. Cecil Charles, Ph.D. P. Murali Doraiswamy, M.D. Deficits in delayed recall of learned information may be an early marker of Alzheimer’s disease (AD). The apolipoprotein E E4 allele and a positive family history (FH) are both genetic risk factors for AD. The authors cross-sectionally compared performance on the California Verbal Learning Test (CVLT) in 153 prospectively recruited normal elderly subjects (mean age 67 years, mean MMSE 28) stratified by genetic risk into four groups (E4 /FH , E4 /FH–, E4–/FH , E4–/FH–). Neither FH nor E4 status affected performance, except on List B (a distraction word list), on which the FH group performed worse. The high-risk group (E4 /FH ) also performed worse on List B than the low-risk group (E4–/FH–) but did not differ on other measures. Memory impairments associated with genetic or family history risk may not manifest until the person is much closer to the onset age of AD.
(The Journal of Neuropsychiatry and Clinical Neurosciences 2002; 14:58–63)

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here is great interest in studying cognitive function in subjects at risk for Alzheimer’s disease (AD).1 The apolipoprotein E E4 (APOE E4) allele is a risk factor for the development of AD, and subjects carrying the E4 allele have an earlier onset of AD.2 Deficits in learning and delayed recall are reported to be among the most sensitive clinical markers of the early stages of AD.3–6 For example, a 13-year prospective study of 1,045 subjects reported that measures of verbal memory were predictive of the development of AD.5 Measures of delayed recall are currently being used as one of the criteria to select individuals for dementia prevention trials. The California Verbal Learning Test (CVLT) is a psychometric assessment designed to measure list learning and verbal memory ability.7,8 Unlike tests that ask a subject to recall stories or remember certain tasks, the CVLT does not provide a semantic or procedural context in which the subject can organize the information presented. Thus it measures explicit or episodic memory9 in adolescent or adult subjects of any age. In addition to simple recall indices, CVLT results can reveal the underlying mechanisms that lead to changes in memory performance, including learning strategies, error types, and learning processes.10,11 CVLT scores correlate highly with both the Verbal Comprehension Index of the Wechsler Adult Intelligence Scale-III and the Auditory
Received June 8, 2000; revised February 21, 2001; accepted March 7, 2001. From the Departments of Psychiatry and Medicine (Geriatrics), Center for the Study of Aging and Human Development, Duke University Medical Center, Durham, North Carolina. Address correspondence to Dr. Doraiswamy, Box 3018, Duke University Medical Center, Durham, NC 27710. E-mail: dorai001@mc.duke.edu. Copyright 2002 American Psychiatric Publishing, Inc.

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J Neuropsychiatry Clin Neurosci 14:1, Winter 2002

and by category (long-delay cued recall). The rater then scored the CVLT with computer software designed by the test’s developers.16. During any of the recall stages. scoring software generates a list of contrast measures that indicate the rate of forgetting METHODS Patient Population Normal elderly subjects ages 55 and older were recruited from a registry of elderly volunteers interested in research. From these data.15 Although the APOE E4 allele itself is not necessarily associated with poorer memory performance. The MR scans are currently still being analyzed. after which he or she is asked again to name the List A words in any order (long-delay free recall). A second. Subjects may adopt a serial learning strategy by simply memorizing the words in order. generating measures of correct answers (recognition hits). All subjects possessed adequate vision and hearing. or a semantic learning strategy by assigning the words to their respective semantic categories. Subjects with pacemakers or other metallic implants that prohibited them from undergoing an MRI were also excluded. Our goal was to recruit at least 25 subjects in each of the above four cells.12 Normative CVLT data have been presented on healthy young. depression. The fact that the words are not prototypic examples of their categories increases the difficulty (for example. with a target of about 40 per cell. and the CVLT. and learning strategy measures (semantic and serial clustering ratios. slacks is in the clothing category.CHEN et al. The subject then is distracted for 20 minutes.11 studied a large sample of elderly subjects (N 212. age. the administrator tests recognition memory by reading a longer list and asking the subject whether each word was on List A or not. Memory and General Memory indices of the Wechsler Memory Scale-III. Finally. Winter 2002 59 . identification of words absent from the list (false positives). composed of four semantic categories of four words each. the subject is asked to name the items from List A freely (short-delay free recall) and by category (short-delay cued recall). age range 55–94) and examined norms broken down by gender. and with and without a positive family history of dementia. a learning rate (the number of words remembered plotted against trial number). Respondents underwent a screening and a brain magnetic resonance imaging scan to rule out significant neurological and psychiatric disorders. with age and education accounting for much less variance in the prediction of cognitive performance. and gave written informed consent. a measure of list learning and verbal memory. different list (List B) designed to interfere with List A is then presented. Within the pool of subjects meeting our initial study criteria. and past strokes were excluded from the study. to screen for cognitive impairment.19 The purpose of this study was to compare CVLT performance cross-sectionally in an elderly sample prospectively stratified by two risk factors for dementia: APOE and family history.13 depressed. Individuals with dementia. using polymerase chain reaction (PCR) amplification and the HhaI restriction digest method of Hixson and Vernier. although some wore glasses and/or hearing aids. Afterwards. ple would have resulted in far fewer subjects with E4 allele and very few subjects E4 /FH– or vice versa.17 some studies have demonstrated that seemingly normal individuals with the E4 allele who are on the verge of developing AD show memory deficits as much as two years before the onset of dementia. but pants is not). so that we would have sufficient sample sizes in each cell to make comparisons of the memory and brain measures. but not by APOE genotype. and recency regions). the subject may name the same word more than twice (a perseveration) or name a word that was not on the original list (an intrusion). and education. generating a summary learning measure (the sum of scores of the five trials). middle. During a CVLT administration. The primary goal of the study was to examine the effects of APOE and family history status on memory and brain chemistry as measured by magnetic resonance (MR) spectroscopy.18. and the percentage of words recalled from the primacy. APOE genotyping was performed with DNA extracted from buffy coat. A sample size of 160 was our target. Studies of normative data on list-learning tests show that gender accounts for a considerable portion of the variance. the main 16-item list (List A) is presented five times.11 Paolo et al. and by newspaper and flyer advertisement. emphasis was placed on recruiting equal numbers of subjects with and without the APOE E4 allele.14 and elderly individuals. This stratification required a two-step recruitment because the APOE alleles and FH are not evenly distributed in the population and a random sam- J Neuropsychiatry Clin Neurosci 14:1. Adjacent words on the list are from different categories. a recall consistency measure (the same words remembered across the trials).20 Assessment Instruments During each visit an experienced rater administered the Mini-Mental State Examination (MMSE).7 The CVLT centers around a 16-item list. and the ability to tell apart valid list words from nonlist words (discriminability).

P 0. 152. education. Although we found a statistically significant negative age effect only on the CVLT summary learning measure. n 59. P 0. P 0. reported an age effect on all eight CVLT recall indices. and gender effects were also predicted from the literature. and forgetfulness.8. and the long delayed free recall measure (F 4. 87 were family history negative (FH–) and 66 were family history positive (FH ). Aside from the CVLT manual. Subjects with ages greater than 65 years demonstrated a greater decline from List A Trial 1 to List B (t 2. There were no significant differences on any measures between the APOE E4 and non-APOE E4 groups. three groups based on education level (completed high school education or less. one CVLT administration generates 28 indices of verbal memory. We did not use the last contrast measure. Table 2 summarizes test performance for subjects grouped by both FH and APOE status. In accordance with the findings of Small et al. n 9) or absence (E2/E2. P 0.05 was used to determine significance for the a priori hypotheses. df 2. df 2. E3/E4.SUBJECTS AT GENETIC RISK FOR AD across various stages during the test. 152. The effect of gender remained significant (P 0.. RESULTS In total. df 151.05). and genetic status on CVLT measures.5.7 7 years. This is also the first report to systematically examine the effects of genetic risk status on CVLT performance in a relatively large aging sample.152. df 152.4 1. learning ability. P 0. percent recall from the recency region (F 4. P 0. learning strategy. The only significant CVLT difference between the FH– and FH groups was on List B scores (t 2. nondemented elderly population stratified by two genetic risk factors for AD. E3/E3.05). Examining age as a continuous variable. and chi-square tests on SAS software were done.0. P 0. Age. Statistical Methods To test the effects of demographic variables. including the summary learning measure (t 4.19 and Bondi et al.8. n 72) of the APOE E4 allele.05) than younger subjects. P 0. All of our subjects were elderly and nondemented. All in all. Female gender and higher education levels were related to better performance. After adjusting for the effects of the other variables.7 only one study. df 1. Winter 2002 . P 0.6 3 and the mean MMSE score was 28. We then used a nonhierarchical linear model to examine the effects of age.6 7 years) than ours (65. df 2. t-tests. The mean number of years of education was 15. FH subjects were younger than FH– subjects (Table 1). including the summary learning measure (F 3.05). Five recall measures.10 we also hypothesized that subjects without E4 alleles would have higher scores than participants with at least one E4 allele. Of all the subjects. P 0. Paolo et al. All analyses were two-tailed. n 4. The age range was 55 to 85.4. In addition. sure. df 152.1.152.5. n 9.3. 81 had no APOE E4 (APOE E4–) alleles.05) declined with age. df 152. 153 subjects (77 males and 76 females) participated in the study. The effect of age as a continuous variable on CVLT performance was also examined. P 0. df 152. Since we had a more limited age range. 60 J Neuropsychiatry Clin Neurosci 14:1. completed or attempted college education.6. percentage change from discriminability to long-delayed free recall.05) and a greater increase from the short delayed free recall measure to the long delayed free recall measure (t –2. n 0.11 has presented normative CVLT data for elderly persons. Women scored higher than men on every recall mea- DISCUSSION We present CVLT data for a normal. and 72 had either one or two APOE E4 alleles (APOE E4 ).05). Both the summary learning measure (F 4.8 7 years). with a mean ( SD) of 66. subjects were divided into two groups around the median age. Paolo et al. General linear models. gender. Women also used semantic clustering more than men (t 2. The only variable that demonstrated a significant difference was once again List B.1. Table 1 displays CVLT scores grouped by APOE E4 and FH status. P 0. Because any group differences were likely to be small. P 0.152.05) and were better at discriminating words (t 2. df 2. the short delayed free recall measure (F 3. the effect of age or E4 status was not significant on any of the recall indices.1. on which the E4–/FH– group performed better than the E4 /FH group (t 2.05) showed significant differences by education status. two groups based on the presence or absence of a family history of dementia.05) and rejecting false positives (t –2.01) in this model for all recall indices as well as four derived measures. and schooling beyond college).05). education.3.6. df 93.0. There were no differences overall. CVLT performance among the education groups differed significantly on only one measure. df 152. df 1.001). a testwise alpha level of 0. E2/E3. P 0.05) on the recognition portion of the test. and two groups based on the presence (E2/E4. df 152. 152. Paolo and colleagues’ group was older (mean age 70. two groups based on gender.05) and the percent recall from the recency region (F 4.. E4/E4. 65. Our findings confirm this report.

67 22.29 6.58 7.83 14.25 41.38 6.26 6.49 6.79 4.04 0. and hence the clinical significance of this finding is puzzling.24 1.99 2.10 reported that E4-positive elderly subjects tested worse on nine different CVLT measures.81 2.08 79.34 2.86 41.58 1.49 27.37 0. Variable Age. We selected a group of subjects from an aging center’s registry of volunteers and by advertisement.95 7.43 15. Alternatively.72 2.05 10.72 62.89 11.05 79. List A trials 1–5 Semantic cluster ratio (observed/expected) Serial cluster ratio (observed/expected) % correct recall from primacy region % correct recall from middle region % correct recall from recency region Slope (increments in words recalled per trial) % recall consistency across trials 1–5 Recall errors.96 12.41 1.24 2.81 1.89 2.61 14. long-delay free recall (% change) *FH vs.CHEN et al. Lists A and B Perseverations (free and cued recall total) Free recall intrusions (total) Cued recall instrusions (total) Intrusions (free and cued recall total) Recognition measures Recognition hits Discriminability False positives Contrast measures List B compared with List A.87 3.59 3.30 2.05.96 2.12 80.92 9.56 1.98 6.36 5.44 1. 72 E4 .04 0.66 59.75 FH (n 87) 66. mean SD Recall measures (number correct) List A trials 1–5 total List A trial 1 List A trial 5 List B List A short-delay free recall List A short-delay cued recall List A long-delay free recall List A long-delay cued recall Learning characteristics. There is interest in using tests of word learning and word recall to detect the early stages of dementia.54 17. It could reflect a spurious finding TABLE 1.01 45/42 49.84 2.63 4.95 2.22 1.34 2. List B is a distraction list.85 2.32 3.65 11.38 0.51 29.55 11.83 6.01 2. our results provide additional data that may enhance the interpretation of these tests in cognitively impaired patients.07 29. In a prior study.66 11.94 29.77 2.89 1.21 57.62 2.08 2.01 0.91 6. we analyzed our data with age split at age 75 (not shown).60 11.51 2.96 11. 35 E4– in Bondi.70 22.73 0. mean age 66 in our study).89 6. P 0.15 4.01 2.06 6.49 1.66 93.47 9.87 14.75 16.20 17.33 10.76 6. Our sample size may have been too small to California Verbal Learning Test (CVLT) scores by presence or absence of APOE E4 alleles and family history (FH) No E4 Alleles (n 81) 68.71 28.97 2.35 5.30 16.66 1. subjects with a family history of dementia performed worse on only one CVLT measure (List B).82 1.84* 2.08 6.74 0.37 3.51 1.38 5.98 7.73 2.75 9. (due to multiple comparisons) or could reflect a true subtle difference in cognitive capacity.91 92.01 30.00 3.01 0.94 2.20 7.95 54.49 1.74 4. List A.02 19.61* 32/34 48.43 1. we confirmed their findings that higher education is associated with better performance on many recall indices.11 11.30 14.94 1.67 0.18 6.62 28. trial 5 (% change) Long-delay free recall vs.84 3. since E4-positive subjects would be expected to perform worse if tested closer to the onset of dementia.77 27.78 4.85 38/43 49.80 4. and subjects with at least one E4 allele did not perform worse on any measures than those without such risk factors. our sample consisted of healthy volunteers and the differences may reflect a sampling effect.58 7.02 43.93 3. However.33 1 E4 Allele (n 72) 65.82 4.38 11.08 2.06 0.66 11.37 8.97 1. In this respect.37 11.45 2.69 5.08 30.66 1.01 0. Winter 2002 61 . by also simultaneously examining the effects of family history of dementia and APOE genotype.32 6.98 2.84 92.35 2.96 0.64 19. mean SD Male/Female CVLT measures.06 2.80 10.35 7. trial 1 (% change) Short-delay free recall vs.09 39/33 48.16 10.41 8. and these analyses tended to confirm the findings by Paolo et al.51 50. This study extends the report of Paolo et al.73 6.73 92. short-delay free recall (% change) Recognition hits vs.73 1.34 10.48 3.23 4.31 10.51 5.37 28. In our population.61 0.33 1.96 J Neuropsychiatry Clin Neurosci 14:1. education. Age differences may explain both our results.19 11.75 11.34 3.92 1.39 1.28 1. like many other cognitive tests. Thus.21 2.87 1.90 0.48 2.64 5. we found that women consistently scored higher than men on both the recall and recognition measures. Bondi and colleagues’ subject pool was smaller (17 E4 . Bondi et al.81 4.15 9.51 41.60 2. FH .07 29.66 2.05 46.96 91.33 2.99 11.23 2. 81 E4– in our study) and 6 years older on average (mean age 71 in Bondi study.15 30. using a planned stratified recruitment design.54 1. there are also some limitations to this report.23 5.84 11. these findings emphasize that the CVLT scores in elderly subjects.81 6.13 FH (n 66) 64.00 10.08 41.51 11.52 2.35 8. Likewise.69 11.29 89.26 0.54 10. years.65 6.37 7.98 9.09 80.90 2. Like those authors.66 2.99 16.49 9.01 1.70 6.61 1.02 49. must also be interpreted in the context of age.73 5.13 2.60 6.89 1. and gender.55 5.50 2.54 1.80 0.

71 18.81* 2.62 3.92 0. In summary. Howieson DB.71 1.22 2. List A trials 1–5 Semantic cluster ratio (observed/expected) Serial cluster ratio (observed/expected) % correct recall from primacy region % correct recall from middle region % correct recall from recency region Slope (increments in words recalled per trial) % recall consistency across trials 1–5 Recall errors. Doraiswamy.84 6.28 2.85 11.32 1.49 0. age.27 1.79 6.32 6.05.96 2.51 1.12 References 1.42 2.77 2.58 93.20 18.15 2.27 1. Variable Age.03 10.64 0.57 9.55 3. Steffens DS.03 28.88 5. Community-based studies of subjects followed longitudinally will be needed to examine these issues further. 45:584–589 62 J Neuropsychiatry Clin Neurosci 14:1. but variable.74 0. long-delay free recall (% change) * P 0.35 10.91 30. and the P-values reported should be interpreted with that in mind. Arch Neurol 1991. Butters N.13 16. This finding may reflect either the relative insensitivity of the CVLT or the fact that memory impairments in at-risk subjects may not occur until the person is much closer to the onset of AD.59 4.83 2.40 10.33 1.32 E4 /FH (n 40) 63. and the higher education level may also have obscured genetic differences on test scores. Camocioli R.43 6. Hughes J. Dame A.69 1.35 5. mean SD Male/Female CVLT measures (mean SD) Recall measures (number correct) List A trials 1–5 total List A trial 1 List A trial 5 List B List A short-delay free recall List A short-delay cued recall List A long-delay free recall List A long-delay cued recall Learning characteristics. Lists A and B Perseverations (free and cued recall total) Free recall intrusions (total) Cued recall instrusions (total) Intrusions (free and cued recall total) Recognition measures Recognition hits Discriminability False positives Contrast measures List B vs.88 1. Doraiswamy PM. et al: Detection of abnormal memory decline in mild cases of Alzheimer’s disease using CERAD neuropsychological measures.87 3.06 8. List A trial 5 (% change) Long-delay free recall vs.71 7.84 2. Neither family history of dementia nor APOE E4 status had a TABLE 2. years.80 4.07 23. detectable consistent effect on any learning or memory measure. National Institute on Aging/Alzheimer’s Association Working Group: Apolipoprotein E genotyping in Alzheimer’s disease.93 5.28 2.32 1.47 22.31 42. et al: Early recognition of Alzheimer’s disease: What’s consensual? What’s controversial? What’s practical? J Clin Psychiatry 1998.04 27.57 8.91 1.08 0.61 6.39 2.65 0. gender. et al: Cognitive markers preceding Alzheimer’s dementia in the healthy oldest old. 48:278–281 4. These results must be interpreted accordingly. This work was supported by the Paul Beeson award from the American Federation for Aging Research and the Novartis Scholar award to Dr.36 5. 347:1091–1095 3.19 1.36 10. 59(suppl 13):6–18 2.74 68.51 3. J Am Geriatr Soc 1997.71 5.78 1.16 2.56 5. The strengths of this study are the careful selection of subjects and the availability of APOE genotyping. and educational level have significant.20 42.65 6.49 6.46 6.09* 18/22 50. effects on the CVLT.12 29.05 2.11 81.41 1.45 3.04 11.12 4. Welsh K.90 11. Tabrizi S.93 7.67 2.50 113.00 14.69 29. List A trial 1 (% change) Short-delay free recall vs. California Verbal Learning Test (CVLT) scores across four groups broken down by APOE E4 status and family history (FH) E4–/FH (n 55) 66.06 81.05 2.66 8.32 1.56 14. Winter 2002 .40 28.91 5.85 92.01 12. Most of these analyses were preplanned.24 2. short-delay free recall (% change) Recognition hits vs.27 10.41 0.15 9. Lancet 1996.21 15.06 54.68 24/31 50.02 58.33 4.24 2.35 0.10 2. We ran multiple analyses and did not adjust for multiple comparisons.SUBJECTS AT GENETIC RISK FOR AD detect subtle differences.23 9.55 3.24 11.51 10.

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