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DOI: 10.1177/0891988714532018

published online 24 April 2014J Geriatr Psychiatry NeurolDina Silva, Manuela Guerreiro, Catarina Faria, Joo Maroco, Ben A. Schmand and Alexandre de Mendona

Significance of Subjective Memory Complaints in the Clinical Setting

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Research Investigation

Significance of Subjective MemoryComplaints in the Clinical Setting

Dina Silva, PhD1, Manuela Guerreiro, PhD1, Catarina Faria, MS2,Joao Maroco, PhD3, Ben A. Schmand, PhD4,and Alexandre de Mendonca, MD, PhD1,5

Abstract

Objective: The clinical significance of subjective memory complaints in the elderly participants, particularly regarding liability ofsubsequent progression to dementia, has been controversial. In the present study, we tested the hypothesis that severity or typeof subjective memory complaints reported by patients in a clinical setting may predict future conversion to dementia. Methods:A cohort of nondemented patients with cognitive complaints, followed up for at least 2 years or until conversion to dementia,underwent a neuropsychological evaluation and detailed assessment of memory difficulties with the Subjective MemoryComplaints (SMC) Scale. Results: At baseline, patients who converted to dementia (36.8%) had less years of formal educationand generally a worse performance in the neuropsychological assessment. There were no differences in the total SMC scorebetween nonconverters (9.5 + 4.2) and converters (8.9 + 4.0, a nonsignificant difference), but nonconverters scored higher inseveral items of the scale. Conclusion: For patients with cognitive complaints observed in a memory clinic setting, the severity ofsubjective memory complaints is not useful to predict future conversion to dementia.

Keywords

memory complaints, memory impairment, Subjective Memory Complaints Scale, clinical setting, Alzheimer disease, mild cognitiveimpairment

Introduction

The clinical significance of subjective memory complaints in

the elderly participants, particularly regarding liability of sub-

sequent progression to dementia, has been controversial. On

one hand, memory complaints certainly represent an important

symptom in clinical practice. The report of memory decline by

patients or informants is part of the core diagnostic features for

mild cognitive impairment (MCI) and Alzheimer disease.1-3

On the other hand, memory complaints are very common in the

general population. For instance, using a formal scale, the Sub-

jective Memory Complaints (SMC) Scale4 as much as 75.9% ofpeople in the community report at least minor complaints when

answering to the question Do you have any complaints con-

cerning your memory?5 Studies with other populations (eg,

Dutch population) have reported a lower percentage of memory

complaints,6 possibly because of a social acquiescence bias of

Portuguese to complain more about their memory.5

It appears that the clinical significance of subjective mem-

ory complaints in the elderly participants might depend, among

other factors, upon the characteristics of participants and the

settings where they are recruited. There might be an important

difference between agreeing that one has some memory diffi-

culties when directly questioned and actively seeking help for

memory problems.7 In a recent study, participants in a clinical

setting had more severe memory complaints and reported more

often forgetting names of family members or friends than those

in the community.8

Regarding participants in the community, a meta-analysis of

cross-sectional studies found that the presence of memory com-

plaints was more frequent in patients with cognitive impairment

than in cognitively normal elderly participants,9 although mem-

ory complaints had modest diagnostic value to establish the pres-

ence of MCI or dementia. Furthermore, subjective memory

complaints may predict future cognitive decline as suggested

by a systematic review of longitudinal studies performed in

1 Dementia Clinics, Institute of Molecular Medicine and Faculty of Medicine,

University of Lisbon, Portugal2 Universidade Lusofona de Humanidades e Tecnologias, Lisbon, Portugal3 Health and Psychology Research Unit, ISPA-IU, Lisbon, Portugal4 Faculty of Social and Behavioural Sciences, University of Amsterdam, the

Netherlands5 Laboratory of Neurosciences, Institute of Molecular Medicine and Faculty of

Medicine, University of Lisbon, Portugal

Corresponding Author:

Dina Silva, Laboratory of Neurosciences, Institute of Molecular Medicine,

Av Prof Egas Moniz, 1649-028 Lisboa, Portugal.

Email: dinasilva@fm.ul.pt

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participants with normal baseline cognitive status.10 A recent

community-based study found that participants with subjective

memory complaints had a high risk of progression to dementia

even if they had normal performance in memory tests.11

In the clinical setting, it is not clear whether the severity or

type of subjective memory complaints in nondemented patients

might be associated with subsequent progression to dementia.

Most longitudinal studies performed in patients with MCI just

considered the presence of memory complaints at baseline as

an entry criterion and did not analyze the severity or the type

of memory complaints as a predictive factor for future conver-

sion to dementia. In fact, in many of these studies, a single gen-

eral question about memory difficulties and not a detailed

formal scale was used.12 Several studies that analyzed in more

detail, using appropriate scales, the memory complaints in

patients with MCI as a predictive factor for future conversion

to dementia generally found that the severity of memory com-

plaints was not predictive.13-15

It could be that specific memory complaints have different

values as predictors of cognitive decline in the clinical setting.

If true, then the type of complaints characterized in a self-report

scale such as SMC would be determinant to identify high-risk

patients and offer them a vigilant follow-up. One study per-

formed in patients with MCI reported that a scale focused on

the current level of cognitive function relative to the past func-

tion could predict future decline.16 In this regard, the report of

slower thinking than before (item 8 of SMC Scale) in our study

could as well be prognostic of future decline. Likewise, general

complaint about memory (item 1 of SMC Scale), which in pre-

vious studies was shown to be more frequently reported in

older people,5 might have a higher score in converters as a sign

of patients insight about their cognitive difficulties.

In the present study, we tested the hypothesis that the

severity of subjective memory complaints or the presence of

specific types of complaints may predict future conversion

to dementia in a clinical setting. For this purpose, a detailed

scale concerning difficulties in daily-life memory tasks, the

SMC Scale, was used.

Methods

Research Participants

Participants were selected from the Cognitive Complaints

Cohort (CCC), established in a prospective study conducted

at the Institute of Molecular Medicine, Lisbon, to investigate

the cognitive stability or evolution to dementia in patients with

cognitive complaints, based on a comprehensive neuropsycho-

logical evaluation and other biomarkers. The CCC is consti-

tuted of nondemented patients with cognitive complaints

severe enough to be referred for a comprehensive neuropsycho-

logical assessment during the period 1999 to 2007, at the par-

ticipating institutions (Laboratory of Language, Faculty of

Medicine of Lisbon; Memoclnica, a private memory clinic

in Lisbon; and the Dementia Clinics, Hospitais da Universidade

de Coimbra). More detailed information concerning CCC

establishment was already published.17 The study was

approved by the local ethics committee.

Inclusion Criteria

1. Subjective cognitive complaints;

2. cognitive assessment with a comprehensive neuropsy-

chological battery (including assessment of subjective

memory complaints);

3. follow-up 2 years (or less if conversion to dementiaoccurred sooner).

Exclusion Criteria

1. Patients with neurological (stroke, brain tumor, signifi-

cant head trauma, and epilepsy) or psychiatric disorders

that may induce cognitive deficits and patients with

major depression according to Diagnostic and Statisti-

cal Manual of Mental Disorders (Fourth Edition, Text

Revision), DSM-IV-TR,18 were excluded;

2. systemic illness with cerebral impact (uncontrolled

hypertension, metabolic, endocrine, toxic or infectious

diseases);

3. history of alcohol abuse, recurrent substance abuse or

dependence;

4. presence of dementia according to DSM-IV-TR.18

From the CCC of nondemented patients with cognitive

complaints referred for neuropsychological examination,

134 patients were selected according to the inclusion criteria,

and from these 1 was excluded (severe head trauma previous

to subjective memory complaints).

Procedures

The baseline comprehensive neuropsychological assessment

was carried out by the same team of trained neuropsycholo-

gists, supervised by MG, following a standard protocol and

comprised several tests and scales:

1. Battery of Lisbon for the Assessment of Dementia

(BLAD)19,20: the BLAD is a comprehensive neuropsy-

chological battery evaluating multiple cognitive

domains. The results were standardized according to the

age and education norms for the Portuguese population

and z scores were calculated. This battery includes tests

for the following cognitive domains: attention (Cancel-

lation Task); verbal(Semantic Fluency), motor, and gra-

phomotor initiatives; verbal comprehension (a modified

version of the Token Test); verbal and nonverbal

abstraction (Interpretation of Proverbs and the Raven

Progressive MatricesAb series B); orientation (per-

sonal, spatial, and temporal); visuoconstructional abil-

ities (Cube Copy); planning and visuospatial/praxis

abilities (Clock Draw); calculation (Basic Written Cal-

culation); immediate memory (Digit Span forward;

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Wechsler Memory Scale [WMS]); visual memory

(Visual Reproduction test; WMS); working memory

(Digit Span backward; WMS); and learning and verbal

memory (Verbal Paired-associate Learning, Logical

Memory and Word Recall; WMS).

2. Trail Making Test (TMT)21,22: The TMT part A mea-

sures psychomotor speed and attention and part B

assesses the ability to shift strategy, executive func-

tions, and visual spatial working memory.

3. Blessed Dementia Rating Scale (BDRS)23,24: the BDRS

is a brief behavioral scale based on the interview of a

close informant; the first part of the scale refers to daily

life activities, the second part to habits, and the third

part to changes in personality.

4. Geriatric Depression Scale (GDS)25-27: the GDS is a

self-report assessment used specifically to identify

depression in the elderly individuals. For this study, a

short form (15 items) of the self-report instrument was

used.

5. Subjective Memory Complaints Scale4,28 for the assess-

ment of subjective memory complaints. Participants

were required to answer 10 individual items concerning

difficulties in daily life memory tasks, with total scores

ranging from 0 (absence of complaints) to 21 (maximal

complaints score). These items are considered represen-

tative of common memory complaints.4

In the present study, no alternative forms of neuropsycholo-

gical tests were used, since the interval between assessments

was long (approximately one year), minimizing any learning

effects.

Outcome

Patients were assessed after a follow-up of at least 2 years or at

time of conversion to dementia. Patients from CCC have

annual clinical consultations at the participating institutions

so it was therefore easier to schedule the reassessments.

Patients who did not attend clinical consultations were con-

tacted by telephone and invited to come to one of the participat-

ing institutions to perform the same neuropsychological battery

of baseline assessment.

Whenever it was not possible to reevaluate the patient in

person, an assessment was performed by a telephone call using

2 validated telephone questionnaires to identify mild cognitive

impairment (MCI) or dementia. We used the Telephone Inter-

view for Cognitive Status that gathers information in the

domains of orientation, concentration, short-term memory,

mathematical skills, praxis, and language. The cutoff used for

dementia was less than 31.29-31 The Dementia Questionnaire

(DQ) was also used in cases of severe cognitive decline or

died patients. The DQ is applied by telephone to caregivers

allowing the diagnosis of dementia using the Diagnostic and

Statistical Manual of Mental Disorders (Fourth Edition, Text

Revision) criteria, and in some cases even to suggest the

dementia subtype (Teixeira J, oral communication, GEECD,

June 3, 2011).32,33 The diagnosis of dementia and Alzheimer

disease was established according to the DSM-IV-TR18 cri-

teria, in a consensus meeting with the neurologist and the

neuropsychologists.

Statistical Analysis

Statistical analyses were performed using IBM SPSS Statistics

19 for Windows (SPSS Inc, An IBM Company, Chicago, Illi-

nois). Comparison of demographic and neuropsychological

data in participants who were clinically stable or converted to

dementia was done using Student t-test on quantitative vari-

ables and the Fisher exact test on the qualitative nominal vari-

ables. Comparison of the SMC total scores between converters

and nonconverters was also performed with the Student t-test.

A multivariate analysis of variance (MANOVA) using Pillais

trace, which is robust to moderate departure of MANOVA

assumptions, was used to test differences in SMC individual

item scores between converters and nonconverters. A Logistic

Regression (LR) analysis (Forward LR method) was also per-

formed to evaluate the effects of age, formal education, depres-

sive symptoms, and SMC on the risk of future conversion

versus nonconversion to dementia. A P value .05 wasassumed as statistically significant.

Results

One hundred and thirty three participants (mean age 68.2 + 9.1)were followed for at least 2 years or until conversion to dementia

(2.6 + 1.5 years for converters and 4.1 + 2.0 for nonconverters,a significant difference, Table 1). During the follow-up period,

49 (36.8%) patients progressed to dementia and 84 (63.2%) didnot. Most patients who progressed to dementia were diagnosed

as Alzheimer disease (80%). The converters had less years offormal education (Student t test, Table 1) and generally per-

formed worse than nonconverters in the neuropsychological tests

administered, with the exception of Cancellation Task, Clock

Drawing Test, Trail Making Test (A and B), Motor and Grapho-

motor Initiatives, Basic Written Calculation, Token Test, and

Digit Span Forward (Student t test, Table 2). There were no sta-

tistically significant differences in the total SMC score between

nonconverters (9.5 + 4.2 [0-21]) and converters (8.9 + 4.0 [0-17]) at the baseline assessment (Student t test, Table 3). A Binary

Logistic Regression analysis was performed to evaluate the

effect of age, formal education, depressive symptoms, and SMC

on the risk of future conversion to dementia. Higher education

was associated with a lower risk of future conversion to demen-

tia, b 0.0961; w2wald (1) 4.242; P 0.040; odds ratio (OR) 0.908, 95% confidence interval (CI) 0.829-0.995. Age,depressive symptoms, and SMC did not predict future conver-

sion to dementia.

Differences in individual SMC items between nonconver-

ters and converters were analyzed with MANOVA, as reported

in Table 3. The Pillai trace test indicated that there are overall

significant differences in the converters versus nonconverters

SMC individual items. (Pillai trace 0.17; F10 2.52;

Silva et al 3

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P 0.009). Nonconverters scored higher than converters inseveral SMC items, namely, item 5 (Do you often use notes

to avoid forgetting things?), item 6 (Do you ever have dif-

ficulties in finding particular words?), and also tended to

score higher in item 3 (Do you ever forget names of family

members or friends?; Table 3).

Discussion

In the present study, performed in a clinical setting, we

hypothesized that the severity or type of memory complaints

could predict future conversion to dementia. The results

showed that the severity of cognitive complaints was not

Table 1. Baseline Demographic and Clinical Characterization Data.a

Converters (n 49) Nonconverters (n 84) P Value

Age, years, mean (SD) 69.9 (8.4) 67.3 (9.4) .11Gender, female/male, n 34/15 44/40 .07b

Formal education, years, mean (SD) 8.1 (4.2) 10.6 (4.8)

predictive. This observation is in agreement with several stud-

ies performed in a memory clinic setting.13-15

In contrast to the initial hypothesis, patients who did not

convert to dementia actually had higher scores on several

items of SMC Scale (items 5 and 6, and also tended to score

higher in item 3). It could be that memory complaints were

more likely associated with depression than with an early

stage of AD. However, converters and nonconverters did not

differ at baseline regarding the presence of depressive symp-

toms. On the other hand, converters showed more deficits in

several areas of neuropsychological assessment, particularly

learning and memory, although they did not differ from non-

converters functionally at the baseline (as assessed by the

BDRS). Patients with more pronounced cognitive deficits

would be in a more advanced stage of the neurodegenerative

disease and thus closer to a decline in functional status and

conversion to dementia.34 Along the disease process, the

insight that a patient has on his or her cognitive impairment

is hindered.35,36 Probably patients deemed to convert tended

to have less subjective complaints just because they already

presented more alteration in insight.

An important aspect is that converters and nonconverters

did not differ at the baseline for important factors that could

influence both conversion to dementia and perception of

memory difficulties. Several longitudinal studies on progres-

sion to dementia found that converters are older than noncon-

verters at baseline,37-39 but in the present study, both groups

were not significantly different. Depressive symptoms can

be associated with subjective memory complaints;40,41 how-

ever, as mentioned earlier, they were not significantly differ-

ent in converters and nonconverters and were correlated with

SMC both in converters and nonconverters (results not

shown). In the present study, converters had less years of for-

mal education. More educated patients were shown to decline

less at early stages of MCI and to decline more at late stages of

MCI as could be anticipated from the cognitive reserve the-

ory.42 It is not clear at the moment whether education could

influence the way patients recognize and report specific mem-

ory complaints, an issue that should be addressed in future

research. It should also be noted that the analysis of subjective

memory complaints in the present study relied on the SMC

Scale, and the results might not be generalizable to other

instruments of memory complaints assessment. However, the

SMC items were selected in such a way to be representative of

common memory complaints.4

A few other aspects deserve comment. A cohort of patients

with cognitive complaints was established irrespective of hav-

ing formal criteria for the diagnosis of MCI. This decision of

not restricting the sample to patients with MCI was taken

because several studies have shown that people with cognitive

complaints and no alterations in the standard neuropsycholo-

gical assessment might also be at risk of future conversion to

dementia.43-45 In a previous longitudinal study from our

group, some patients with cognitive complaints and no altera-

tions in the standard neuropsychological assessment pro-

gressed to dementia and interestingly, as a group, had a

decline in hippocampal volumes.46 Anyway, most (82%) ofthe patients recruited in the present longitudinal study would

fulfill the criteria for MCI,1 and the observed annualized con-

version rate (14%) fits quite well the values previouslyreported for patients with MCI.47

The clinical significance of subjective memory complaints

in the elderly individuals likely depends upon the characteris-

tics of participants and the settings where they are recruited.

Table 3. Subjective Memory Complaints in Converters and Nonconverters to Dementia.a,b,c,d,e

Converters(n 49)

Nonconverters(n 84)

StatisticalTestf

StatisticalSignificancef

Mean (SD) Mean (SD) F P Value

1. Do you have any complaints concerning your memory? 2.00 (0.82) 2.00 (0.71)

In healthy people living in the community, subjective memory

complaints may help predict future cognitive decline.10 Like-

wise, in a general practice consultation population, the pres-

ence of memory complaints was reported to be a significant

independent predictor for subsequent hospital-based dementia

diagnosis.48 On the other hand, the present study shows that

in a memory clinic setting, where patients with cognitive com-

plaints have a higher risk of future conversion to dementia, the

severity of subjective memory complaints is no longer useful to

predict outcome. Even so, the use of scales to assess subjective

cognitive complaints may be important for the characterization

of the perceived difficulties and the planning of a comprehen-

sive rehabilitation strategy.

Acknowledgments

The authors thank Memoclnica for the facilities provided.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to

the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the

research, authorship, and/or publication of this article: This work was

supported by Fundacao para a Ciencia e Tecnologia (grant number:

PTDC/EIA-EIA/111239/2009).

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