1. Subjective memory complaints, mood and MCI: A follow-up study
Jen Yates, Linda Clare, Bob Woods and MRC CFAS
Bangor University

2. Background: Subjective memory complaints (SMC)
People report problems with, or changes in, their memory
Common in older people
Assessments vary from brief questions to in-depth questionnaires such as the Memory Functioning Questionnaire (MFQ; Gilewski et al., 1990)
SMC are related to a lower quality of life for older people
(Mol et al., 2006; Iliffe & Pealing, 2010)
SMC can occur when older people report memory problems or changes in their memory for example: not being able to remember where their glasses are, appointments, or mentioning that their memory is not as good as it used to be.
Brief questions: have you noticed any changes in your memory?

3. Background: Mild cognitive impairment (MCI)
A concept developed to describe the transitional phase between normal and pathological ageing
Criteria include objective impairment in memory or other cognitive domain, intact general cognitive functioning, intact activities of daily living, absence of dementia, presence of SMC
However, there are 19 variations of this criteria so far
Only ten versions of the criteria include SMC
As many as 62% of individuals who experience cognitive
decline do not report SMC (Illife & Pealing, 2010)
Think about a continuum between normal ageing and pathological ageing such as dementia – MCI sits in between this
A-MCI: memory impairment
N-MCI: impairment in another cognitive domain such as language
M-MCI: impairments in more than one cognitive domain, memory or otherwise
Objective impairment measured through tests of cognitive function and cut off scores are used to determine what constitutes impairment
19 variations differ in the extent to which they endorse the criteria listed above
Individuals who experience cognitive decline but do not report SMC are missed from the MCI diagnosis – this lowers the prevalence of MCI and people who have cognitive impairment are likely to miss out on receiving assistance

4. Background: Mood SMC have been related to depression and anxiety
Depression may enhance negative attributions and distort the subjective appraisal of memory
Increases in anxiety have been associated with increases in SMC despite no decrease in objective memory performance
Symptoms of anxiety and depression are increased in people classified as having MCI
Anxiety and depression may indicate a risk factor for
the development of MCI, a reaction to the onset of
cognitive decline, or both
Several ways the relationship between mood and SMC may operate:
People with depression may appraise their memory more negatively
Depression can cause temporary cognitive disturbances
Worried well: anxiety may cause people to worry more about their memory
Anxiety may cause people to be more vigilant to changes in their memory
Recent systematic review and meta analysis conducted by our team found that anxiety and depression were increased in people with MCI

5. Research questions:
Are people with MCI more likely to have symptoms of anxiety or depression than people with normal cognitive functioning?
Are people with SMC more likely to report symptoms of anxiety or depression than people without SMC?
Does anxiety or depression at baseline predict the presence of SMC after two years?

6. Methods: Design
Medical Research Council Cognitive Function and Ageing Study (MRC CFAS)
Longitudinal population based study involving participants from five areas of England and Wales
Participants were initially screened regarding general health and day to day activities
A subsample completed a detailed assessment
Participants were assessed again after 24 months
Baseline and follow-up data is presented in this analysis
MRC CFAS conducted in 1990 onwards
Over participants originally screened
2640 selected for detailed assessment which included cognitive measures and measures of mood

7. Methods: Participants
People aged over 65 years and living in Gwynedd, Cambridge, Nottingham, Newcastle and Oxford areas
Randomly sampled between 1990 to 1991
Participants were excluded from the analysis at baseline if they had a diagnosis of dementia (n=587), impaired ADLs (n=475) or other cognitive impairment no dementia (OCIND; n=234)
1344 participants at baseline and 896 participants at
follow-up
Details of participants were obtained from GP records

8. Methods: Classification of SMC and mood
SMC indicated by self report of memory problems by the participant
“Have you had any difficulty with your memory?”
Anxiety and depression were used to investigate mood
Geriatric Mental State Automated Geriatric Examination for Computer Assisted Taxonomy (GMS-AGECAT)
A score of two indicated mild symptoms and a score of
three indicated a definite case. Participants with scores
of two or higher were considered in this analysis
SMC was a question in the interview and resulted in a dichotomous category
AGECAT is an algorithm which is used to classify symptoms of mood based on the questions asked in the interview.

9. Methods: Classification of MCI
MCI was defined according to Petersen criteria and included the amnestic, non-amnestic and multiple-domain subtypes
MCI: objective cognitive impairment, intact ADLs, intact general cognitive function, SMC and no diagnosis of dementia
MCIW: participants meet criteria for MCI but do not have SMC
OCIND: other cognitive impairment no dementia. Participants have general cognitive decline, intact ADLs and did not meet
criteria for dementia
ADL: participants with impairments in ADLs and general
cognitive decline but did not meet criteria for dementia
Dementia was determined by the AGECAT algorithm.

10. Results: Descriptives
787 (58.6%) of participants had SMC at baseline
49.5% of participants had MCI or MCIW at baseline
Table 1: Sample characteristics for participants with and without subjective memory complaints at baseline.
Baseline
Follow-up
No SMC
SMC
Total
Age mean(sd)
73.69 (6.15)
74.56 (6.50)
1344 (100)
75.41 (6.17)
76.68 (6.62)
896 (100)
MMSE mean (sd)
25.13 (3.69)
24.86 (3.49)
25.40 (3.47)
25.07 (3.13)
Female N(%)
501 (63.7)
360 (64.6)
433 (65.7)
151 (63.7)
Years in FT Education mean (sd)
9.86 (2.13)
10.03 (2.23)
9.98 (2.12)
10.12 (2.32)
Without depression (%)
629 (79.9)
370 (66.4)
546 (82.9)
141 (59.5)
With depression (%)
158 (20.1)
187 (33.6)
113 (17.1)
96 (40.5)
Without anxiety (%)
766 (97.3)
514 (92.3)
651 (98.8)
214 (90.3)
With anxiety (%)
21 (2.7)
43 (7.7)
8 (1.2)
23 (9.7)
Total (%)
787 (58.6)
557 (41.4)
659 (73.5)
237 (26.5)
Level of SMC and cognitive impairment according to our definitions is relatively high
Few differences otherwise between people with SMC and without in terms of age, education, mmse.
Less people at follow-up for reasons such as elective withdrawal, death and moving out of study area.

11. Results: Changes in cognitive status over two years
Several participants changed cognitive status over the two-year period
Change in cognitive status over the two years from baseline to follow-up – perhaps depression is acting as a reaction to worsening cognitive decline, or both part of a similar pathological process

12. Results: Are people with MCI more likely to have anxiety or depression?
The odds of having symptoms of anxiety or depression at baseline were significantly increased in participants classified as MCI
The odds of having symptoms of anxiety or depression at baseline were decreased in participants classified as MCIW
The odds of having symptoms of depression at follow-up were increased in participants classified as MCI at baseline
The odds of having symptoms of depression at follow-up
were increased in participants classified as MCI at
follow-up
Only difference between MCI and MCIW participants is presence of SMC
Depression increased at follow-up for those who had MCI at baseline and at follow-up: Note – these are not necessarily the same people as people can change categories in any direction.

13. Results: Are people with SMC more likely to have anxiety or depression?
The odds of having symptoms of anxiety or depression were higher in participants who reported SMC compared to those who did not report SMC at baseline and at follow-up
A significant association was found between the presence of anxiety or depression at baseline and the presence of SMC at follow-up
The relationship remained significant after anxiety and
depression at follow-up were controlled for, with anxiety
accounting for 44% and depression accounting for 41%
of the variance in SMC at follow-up
Having anxiety or depression at baseline might lead to the development of SMC after two-years

14. Discussion: Main findings
Symptoms of anxiety and depression were increased in people with MCI, but decreased in people with MCIW
Symptoms of anxiety and depression were increased in people with SMC, and were associated with the presence of SMC after two years
Suggests that anxiety and depression may be related to SMC rather than cognitive impairment.

15. Discussion: Limitations
Sample size at follow-up is small and may have impacted on statistical power
Progression from one cognitive status to another does not happen in a straightforward manner
The presence of SMC in participants is unstable over time
Questions used in the interview to assess anxiety and depression may not be sensitive enough to draw out less severe or
less frequent instances of symptoms
The numbers of people reporting anxiety at baseline with or without SMC were just 8 and 23, so very small.
Participants can move from MCI back to no cognitive impairment for example, people don’t progress in a linear fashion which does make seeing changes quite difficult
Some participants who have SMC at baseline no longer report it at follow-up
We did include AGECAT level 2 to account for milder symptoms

16. Discussion: Strengths
CAMCOG is a well-established screening tool
The MCIW category has not been used in previous research to directly compare to participants classified as MCI
Large, representative population sample
CAMCOG is used in many studies and in clinical practice
MCIW category allows a direct comparison between people with SMC and without as the participants are similar in terms of other criteria that they meet.
Due to the sampling nature from GP surgery lists and method of approach it ensured the sample was very representative and did not consist of people who had been identified through service/hospital use, as can be common in studies of older people.

17. Discussion: Implications
The MCIW category shows that a large number of people who would otherwise meet criteria for MCI are missed due to not reporting SMC
Reporting of SMC could be investigated further by health professionals as it may indicate presence of anxiety or depression in addition to, or instead of, memory problems
Future research could be conducted using more frequent time points to detect change in cognitive function and assess
the stability of SMC
Early intervention in cognitive problems can help to slow down the development of further cognitive decline. People diagnosed as having MCI progress to dementia at a rate of 10-12% annually compared to people with normal cognitive functioning at a rate of 3% annually.
SMC may be a marker for other issues, such as anxiety or depression. As such, older people reporting memory problems could be asked about their mood as well as their memory to see if help could be offered.
Due to unstable nature of MCI and SMC, more frequent time points could used in future research to see how quickly or how often participants change cognitive status

18. For further information please email j.yates@bangor.ac.uk
Thank you
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