C International Psychogeriatric Association 2013

International Psychogeriatrics: page 1 of 11 

doi:10.1017/S1041610213002263

Subjective memory complaints, depressive symptoms and

cognition in patients attending a memory outpatient clinic
...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

J. Lehrner,1 D. Moser,1 S. Klug,1 A. Glei,2 E. Auff,1 P. Dal-Bianco1 and G. Pusswald1

1
2

Department of Neurology, Medical University of Vienna, Vienna, Austria

Center for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Vienna, Austria

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.

risk for dementia. The majority of longitudinal

studies have identified SCI as predictor for future
decline (Reid and MacLullich, 2006). In a followup study of healthy older people with SMC over
seven years, it was reported that 8% of the sample
progressed to mild cognitive impairment (MCI),
a condition with impaired cognitive functions,
although criteria for dementia are not met yet
(Albert et al., 2011), or dementia proper (Reisberg
et al., 2010). The risk in SCI of declining to a
diagnosis of MCI was 10% over three years in a
recent study, about three times higher than what is
seen in persons without SCI (Jessen et al., 2010).
There is a growing body of evidence suggesting
that SMC are related to early AD-related brain
changes. A variety of studies have demonstrated a
relationship between SMC and putative biomarker
evidence such as brain activation on functional
imaging (Erk et al., 2011), cerebral hypometabolism
(Scheef et al., 2012), gray matter volume loss
(Saykin et al., 2006), amyloid accumulation

J. Lehrner et al.

(Perrotin et al., 2012), and cerebrospinal fluid

markers (Visser et al., 2009).
There has been inconsistent empirical evidence
to date about the link between SMC and
actual cognitive functioning including memory
performance. Some previous literature suggests that
SMC are related to cognitive performance (Lam
et al., 2005; Jessen et al., 2007; Clement et al.,
2008; Slavin et al., 2010), whereas other studies
have not found such a relationship (Jungwirth et al.,
2004; Purser et al., 2006; Lenehan et al., 2012).
Instead, it has been related to depressive symptoms
(DS) and personality (Abdulrab and Heun, 2008;
Stewart, 2012). This may be partly due because
the possible approaches to eliciting and assessing
SMC are highly variable in the literature (Reid
and MacLullich, 2006) and there is no consensus
regarding as to which aspects of patient-reported
SMC are most predictive of cognitive impairment
(Abdulrab and Heun, 2008). In some studies,
SMC were solicited, and in others, they were
volunteered. Furthermore, some studies have used
simple one-item questions, while others used a
battery of questions. Based on previous studies,
which showed better results for current memory
self-ratings compared to the endorsement of general
memory worsening in the past year (Snitz et al.,
2008) we used a psychometric validated measure
to investigate current SMC (past four weeks) in
patients attending a memory outpatient clinic.
Specifically, we were interested in the prevalence
of SMC and whether SMC were related to DS,
cognitive performance, and cognitive status. We
hypothesized that patients attending a memory
outpatient clinic will report more SMC compared
to a cognitively healthy control group and that MCI
classification will lead to a higher prevalence rate
than SCI classification.

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

magnetic resonance imaging (MRI) scan of the

brain was obtained. In determining significant
cerebrovascular disease, both neuroimaging and
clinical patient features were used. All participants
were subjected to the Neuropsychological Test
Battery Vienna (NTBV) that included attention,
executive functioning, language, and memory
domains with corresponding domain z scores
(Lehrner et al., 2007). A total z-score across all
tests was also computed (Pusswald et al., 2013).
The Alters-Konzentrations-Test (AKT) (Gatterer,
2008), a geriatric cancellation test, the digit symbol
subtest of the German WAIS-R (Tewes, 1994), the
symbol counting task from the cerebral insufficiency
test (C.I.) (Lehrl and Fischer, 1997), the Trail
Making Test B (Reitan, 1979), and the score
difference of the Trail Making Test A and B (Reitan,
1979) were applied to assess attention. Executive
functions were investigated using the Trail Making
Test A (Reitan, 1979), the Five-Point Test (Regard
et al., 1982), the Maze Test from the NAI Test
Battery (Oswald and Fleischmann, 1997), the
Stroop Test from the NAI Test Battery (Oswald and
Fleischmann, 1997), and the interference test from
the C.I (Lehrl and Fischer, 1997). Naming as many
words beginning with the letters b, f, and l that came
to mind within one minute for each task was used to
tap lexical verbal fluency. In order to test language
functions, we used verbal fluency tasks and a
confrontation naming task (Goodglass and Kaplan,
1983). Naming as many animals, supermarket
items and tools that came to mind within one
minute for each task was used to tap semantic
verbal fluency. The modified Boston Naming Test
(mBNT)(Morris et al., 1989) was used for assessing
naming capabilities. Episodic memory was tested
using the Verbal Selective Reminding Test (VSRT)
with the subtests of immediate recall, total recall,
delayed recall, and recognition (Lehrner et al.,
2006).
Inclusion and exclusion criteria were similar to
other studies. Patients were excluded from the
study if any of the following conditions applied: (i)
evidence of stroke as determined by neuroradiologic
and clinical examination, (ii) history of severe head
injury, (iii) current psychiatric diagnosis according
to ICD-10 (Dilling et al., 2000), however, patients
with (sub-) depressive symptoms were included
because (sub-) depressive symptoms often occur
in elderly patients, (iv) any medical condition that
leads to severe cognitive deterioration including
renal, respiratory, cardiac, and hepatic disease, and
(v) diagnosis of dementia according to DSM IV
(Sa et al., 2003).
After the completion of the evaluation, the
cognitive status of MCI subtypes was determined
according to the Peterson criteria (Petersen and

Subjective memory complaints, depression and cognition in a memory outpatient clinic

Morris, 2005), and the cut-off score used was

1.5 standard deviations below age and education
corrected norms using a normative sample of
cognitively healthy controls. For this purpose, the
flexible GAMLSS (Generalized Additive Models
for Location, Scale and Shape) model class was
used (Stasinopoulus and Rigby, 2007; Pusswald,
et al., 2013). The mean mode of MCI classification
was used and patients were divided into three
groups of patients based on cognitive features
as follows: subjective cognitive impairment (SCI)
patients (mean z-scores of each domain were greater
than 1.5 SD), amnestic MCI (mean z-score of
the memory domain was below 1.5 SD) and nonamnestic MCI patients (mean z-scores of at least
one domain other than memory domain were below
1.5 SD), respectively.
Patients
Five-hundred eighty-one consecutive patients
complaining about memory problems who came
to the memory outpatient clinic for assessment
of a possible cognitive disorder and fulfilled the
inclusion criteria were included in the study.
Patients were either referred by physicians or were
self-referrals. Mean age of patients was 66.4
9.2 years. Altogether, 40.6% of the patients were
male and 59.4% were female. Mean years of formal
education was 11.8 3.7. The median MMSE
performance of patients was 28 (quartile 2729).
Subtyping procedure of patients revealed that 366
patients are in the SCI group, 134 patients are in
the naMCI group, and 81 patients are in the aMCI
group, respectively. Mean age of SCI patients was
66.0 9.4 years. Altogether, 40.4% of the SCI
patients were male and 59.6% were female. The
median of years of formal education of SCI patients
was 11 (quartile 814). The median MMSE
performance of SCI patients was 29 (quartile 27
29). Mean age of naMCI patients was 68.0
9.1 years. Altogether, 39.5% of the naMCI patients
were male and 60.5% were female. The median
of years of formal education of naMCI patients
was 10 (quartile 814). The median MMSE
performance of naMCI patients was 28 (quartile
2729). Mean age of aMCI patients was 65.4
8.3 years. Altogether, 43.2% of the aMCI patients
were male and 56.8% were female. The median
of years of formal education of aMCI patients
was 12 (quartile 815). The median MMSE
performance of aMCI patients was 27 (quartile
2628).
Cognitively healthy control subjects
Great care was taken enrolling a sufficient number
of cognitively healthy control subjects living inde-

pendently at home. Control subjects were recruited

by means of advertisements. They underwent a
rigorous screening evaluation using a standardized
clinical interview and cognitive screening. Imaging
procedures, neurological examination, standard
laboratory blood tests, and informant reports
were not included in the evaluation. They were
assessed as being in good health. Criteria for
healthy function were identified as being similar
to those in the Mayo research studies (Ivnik et.al.,
1992): (i) no active neurological or psychiatric
disease, (ii) no psychotropic medications, and
(iii) the subjects may have medical disorders but
neither they nor their treatment compromises
cognitive function. Cognitive status was given
special attention and cognitively healthy control
subjects were screened for intact cognition. They
were required to have an MMSE score greater than
or equal to 27 and a MOCA score greater than or
equal to 26 adjusted for education. Twohundred
forty-seven elderly controls were included in the
study.
Mean age of controls was 66.3 8.4 years.
Altogether, 58.3% of controls were male and
41.7% were female. Mean years of formal
education were 11.5 3.8. The median MMSE
performance of patients was 29 (quartile 2829).
The neuropsychological performance of controls
and patient groups are reported in Table 1.

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.

class (Stasinopoulus and Rigby, 2007; Pusswald,

et al., 2013). The measure has been shown
to be internally consistent (Cronbachs alpha =
0.85). Participants indicating a considerable degree
of SMC defined as complaining at least 1.5 SDs
below of the age, sex, and schooling specific mean
of the normative sample are reported.
Assessment of depressive symptoms (DS)
The Beck Depression Inventory (BDI-II), a 21item instrument to detect DS in adults was used.
It asks about how often one felt certain ways within
the past two weeks, rated on a four-point scale. A
score above ten is indicative of clinical relevant DS
(Hautzinger et al., 2006).

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.

Subjective memory complaints, depression and cognition in a memory outpatient clinic

Table 2. Forgetfulness Assessment Inventory (FAI) self-report

NEVER

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.

Correlation analysis for the patient group

between FAI z-score and MMSE, BDI-II score and
neuropsychological test scores (single test z-scores
as well as domain test z-scores and total z-score)
revealed low correlation coefficients (all rs below
0.18) except for BDI-II, which showed a moderate
association (r = 0.29). All correlation coefficients
were statistically significant (all ps < 0.05). See
Table 3 for details.
In order to investigate the influence of cognitive
status of controls and patients on FAI, we further
categorized the study population into a control
group, a SCI group, a naMCI group, and a aMCI
group. Mean FAI z-score was 0.03 1.01 for
the control group, 0.93 1.32 for the SCI
group, 0.85 1.25 for the naMCI group, and
1.62 1.41 for the aMCI group, respectively. An
analysis of variance revealed a statistically significant
difference in FAI between the four groups (p <
0.001). Pairwise post-hoc comparisons detected
significant differences for all pairwise comparisons
(Tukey-corrected p < 0.001) except for SCI versus
naMCI.
The frequency of considerable SMC in controls
and SCI subgroup, naMCI subgroup and aMCI
subgroup is also reported. Whereas only roughly 8%
of controls reported considerable degree of SMC,
34% of the SCI group, 31% of the naMCI group,
and 54% of the aMCI group showed a considerable
degree of SMC. See Figure 1.
In order to investigate the influence of cognitive
status of patients on DS, we performed an analysis
of variance with the factor cognitive status (controls,
SCI group, naMCI group, and aMCI group) and

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

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.

log-transformed BDI score as a dependent variable.

Median BDI-score was 5 (29) for the control
group, 10 (614) for the SCI group, 11 (618)
for the naMCI group, and 9 (515) for the aMCI
group. An analysis of variance revealed a statistically
significant difference between the four groups (p <
0.001). Pairwise post-hoc comparisons detected a
statistically significant difference between controls
and all patient groups (Tukey-corrected p < 0.001).
See Figure 2. Whereas 16.6% of controls reported
DS, 48.6% of the SCI group, 52.2% of the naMCI

group, and 42.0% of the aMCI group showed

significant DS, respectively.
Additionally, we investigated whether depressive
status and cognitive status had an impact on SMC.
We performed a two-factor analysis of variance with
the factor cognitive status (controls, SCI group,
a naMCI group, aMCI group) and the factor
depressive status (depressed vs. not depressed)
and FAI z-score as a dependent variable. Both
factors were significant (p < 0.001), whereas the
interaction was not (p = 0.820). This means that

Subjective memory complaints, depression and cognition in a memory outpatient clinic

Percent
90
85.43%
80

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

the prevalence of depression in elderly individuals

seeking help for cognitive problems in hospitals
(Panza et al., 2010).
A correlational analysis found low-correlation
coefficients between SMC as measured by FAI
except for BDI-II which showed a moderate
association. This finding is in accordance with
previous research showing that in SCI-patients and
MCI-patients, SMC are more strongly associated
with DS than cognitive functioning (Reid and
MacLullich, 2006; Abdulrab and Heun, 2008;
Stewart, 2012).
When cognitive status was taken into account,
we found that SMC significantly differed across
controls and patient groups except for SCI versus
naMCI. Whereas only 8% of controls reported
considerable SMC, roughly one-third of SCI
and naMCI patients and about half of aMCI
patients reported considerable SMC, respectively.
Furthermore, all three patient groups reported
significantly more DS compared to controls,
however, patient groups did not differ. Whereas
16% of controls reported DS, almost half of the
SCI group and more than half of the naMCI group
showed significant DS. In contrast, only 42% of
the aMCI group showed significant DS. All of the

J. Lehrner et al.
50

Beck Depressions Inventar

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.

patients reporting significant DS were subsequently

referred to a neurologist/psychiatrist to take into
consideration anti-depressive treatment.
Our findings demonstrate that SMC are
increasing from cognitively healthy to aMCI and
therefore may go along with neuropathologic AD
manifestation in these patient groups (Jessen et al.,
2010; Stewart, 2012). DS were most often found
in naMCI patients, indicating that there may be an
association with vascular damage, because vascular
processes have been found in depressed patients
with naMCI (Naismith et al., 2012).
An important goal of the current study was
to investigate the relationship between SMC
and depressive status and cognitive status. We
found that SMC differed across all groups and
that patients with depressive symptomatology had
significantly more SMC across all groups compared
to patients without depression. Thus, the main new
finding of the present study is that SMC are directly
related to cognitive status independent of depressive
status. There is a possible clinical continuum from
cognitively healthy persons to aMCI regarding
SMC and depressive status is exerting a negative

influence by increasing SMC across all groups

investigated.
A number of factors may have influenced
the findings and should be considered when
interpreting the results. Prevalence of SMC and DS
may vary as a result of different diagnostic criteria
and different sampling and assessment procedures.
For instance, SMC and DS may be higher in
hospital-based studies than in population-based
studies reflecting different referral patterns and
selection criteria (Panza et al., 2010). A common
underlying factor regarding reporting memory
complaints and depressive symptoms might be
a certain personality style (Stewart, 2012). The
present study did not address this question but in
further studies it should be integrated as control
measure.
There are a number of strengths of this cross
sectional study. Assuming that SCI and MCI
may be the earliest identifiable clinical stages
of dementia, SMC and DS may be an early
manifestation or a risk factor for dementia and
Alzheimer disease. For this reason, it is important to
know the relationship between memory complaints

Subjective memory complaints, depression and cognition in a memory outpatient clinic

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.

and depressive symptoms in patient groups with

different cognitive status. Furthermore, it is
important to know the prevalence of memory
complaints and depressive symptoms in these
patient groups. The present study used a wellcharacterized patient sample with sufficient sample
sizes in order to clarify these important questions.
For patients with SCI and patients with
MCI reporting considerable SMC and DS, the
findings on increased risk of incident MCI or
its progression to dementia are conflicting (Reid
and MacLullich, 2006; Panza, et al., 2010). More
longitudinal studies are needed to investigate the
predictive validity of SMC and DS in predicting
future cognitive decline and dementia. A current
investigation by our group is underway to clarify
this question.
In conclusion, a large proportion of patients
seeking help in a memory outpatient clinic report
considerable memory problems, with an increasing
degree from cognitively healthy elderly to patients
with amnestic MCI. SMC are directly related
to cognitive status independently of depressive
status, however, depressive status increases SMC

consistently across groups with different cognitive

status.
Conflict of interest
None
Description of authors roles
Dr Lehrner designed the study, supervised the
data collection, and wrote the paper. Dr Moser
collected the data and assisted with writing the
paper. Dr Klug collected the data and assisted with
writing the paper. Dr Glei was responsible for the
statistical design of the study and for carrying out
the statistical analysis. Dr Auff designed the study
and assisted with writing the paper. Dr Dal-Bianco
collected the data and assisted with writing the
paper. Dr Pusswald collected the data and assisted
with writing the paper.

Acknowledgment
The authors thank Arinya Eller for proofreading this
manuscript.

10

J. Lehrner et al.

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