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This is to certify that the
thesis entitled

SELECTIVE REMINDING (SR)
IN THE DIFFERENTIATION OF DEPRESSION FROM DEMENTIA

presented by
DAV I D BACHRACH FI NKE

has been accepted towards fulfillment
of the requirements for

M.A. degree in Psychology

ATM. TM

Major professor

Date IOLZ‘T'IIQ'TD

0—7639 MSU is an Affirmative Action/Equal Opportunity Institution

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MSU Is An Affirmative ActiorVEqual Opportunity Institution
c:\circ\ddodua.prn3-p.1

SELECTIVE REMINDING (SR)
IN THE DIFFERENTIATION OF DEPRESSION FROM DEMENTIA

By
DAVID BACHRACH FINKE

A THESIS

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTER OF ARTS

Department of Psychology

1990

@45- ”1/84,

ABSTRACT
SELECTIVE REMINDING (SR) IN THE DIFFERENTIATION 0F DEPRESSION
FROM DEMENTIA
By

David Bachrach Finke

This study investigated the ability of the Selective
Reminding Task, a test of verbal memory, to differentiate
among elderly participants with mild dementia and mild
depression. Participants were screened for mild depression
and mild dementia and were administered the SRT. While the
total number of words recalled distinguished between healthy
and demented individuals, there was no distinction between
participants with mild depression and those with mild
dementia, or those with mild depression compared to healthy
participants. A fourth group of participants with both mild
depression and mild dementia was analyzed. Again, only
recall was able to distinguish this group from the healthy
participants, and recall did not differentiate among the
impaired groups. In addition, age and education had no
significant effects on the participants' performance. Gender
appeared to have a significant effect on all SRT variables.
The implications of these findings, as well as possiblities

for future research, were discussed.

This thesis is dedicated to the memory of my loving mother
whose dream is realized with the completion of this work.
You deserved much more than you received.

I miss you.

Love,

Dave

iii

ACKNOWLEDGMENTS

I am grateful to the members of my thesis committee, Ray
Frankmann and Dozier Thornton, and my thesis chair, Norman
Abeles, for their guidance and flexibility on this project.

I also wish to thank Mike, Marianne, and Bruce for their
advice and support, not just now, but all my life. It has
led to this moment.

Last, but certainly not least, I am beholden to you, Helene,

for your support, advice, and, most of all, patience
throughout my neurotic rantings.

iv

TABLE OF CONTENTS

List of Tables ............................................. vi
Introduction ................................................ 1
Diagnosing Dementia and Alzheimer’s .................... 3
Memory and the Information—Processing Model ............ 8
The Selective Reminding Task and Memory Impairment ..... 9
Alzheimer's, Depression, and Memory Impairment ........ 15
Hypotheses ................................................. 17
Method ..................................................... 19
Participants .......................................... 19
Measures .............................................. 21
Procedure ............................................. 22
Results .................................................... 24
Analyses of Hypotheses ................................ 24
Ad Hoc Analyses ....................................... 27
Discussion ................................................. 37
Appendix A: Beck Depression Inventory (BDI) ................ 47
Appendix B: Senile Demenia of the Alzheimer's Type
Battery (SDAT-battery) ................................ 49
Appendix C: Selective Reminding Task (SRT) ................. 55
List of References ......................................... 57

Table
Table

Table

Table

Table

Table
Table
Table

Table
Table

Table

10:

11:

LIST OF TABLES

Demographic Information by Group ................. 20

Screening Characteristics of Sample by Group ..... 20

Means and Standard Deviations for All

Groups, Across Variables .................... 25
Correlation Analysis of CLTR and LTR ............. 28
Regression Analyses of Age, Education, and

Gender as Covariates ........................ 31
Univariate Tests for Interactions ................ 32
Age within Group Analysis of CLTRzLTR ............ 33
Significance of Regression Lines in Age by

Group Interaction of CLTR:LTR ............... 33
Education within Group Analysis of Recall ........ 35

Significance of Regression Lines in Education

by Group Interaction of Recall .............. 35

Performances on Dependent Variables by Gender...

.36

INTRODUCTION

Improvements in health care have caused a tremendous
increase in the average life expectancy of individuals in our
society. Regardless of the changes in modern medicine, no
one has discovered how to expand the capacity or lifespan of
the human brain. Thus, while we are able to slow the natural
deterioration of our bodies and increase human lifespan,
efforts to preserve the higher cortical functions of the
brain, such as memory and abstract thinking, have been
largely unsuccessful.

As a consequence, dementia, in general, and Dementia of
the Alzheimer's Type (DAT), in specific, have become a topic
of increasing concern to mental health professionals in
recent years. 402 articles were published on Alzheimer’s
Disease in American Psychological Association Journals during
the past 6 years: A sharp contrast to the 30 articles
published on the same topic in the same journals during the
nine previous years.

The generic term "dementia" refers to the impairment of
higher brain functions, such as memory, abstract thought, and
judgment (Botwinick, 1984). The diagnosis of dementia is
given if the impairment stems from an organic base (DSM III-
R, 1987). The organic brain disorders which cause dementia
can be temporary, such as those due to malnutrition or brain
toxicity, or permanent. The two most common causes of

permanent dementia in the elderly are Multi-infarct Dementia

(MID) and Dementia of the Alzheimer’s Type (DAT). MID occurs
in approximately 12 to 17 per cent of dementia cases
(Botwinick, 1984). It is vascular in origin, and is the
result of many small infarcts, or strokes. The infarcts
restrict the flow of blood through the brain tissue,

resulting in dead brain tissue (McLean, 1987).

DAT is more prevalent and generally considered more
debilitating than MID (Botwinick, 1984). Estimates of the
prevalence of DAT in those aged 65 and over range from 2 to 4
percent by some accounts (DSM III-R, 1987; Gatz & Pearson,
1988), while others report that 15 percent of all elderly
have senile dementia - 80 percent of which are of the
Alzheimer's type (La Rue, Dessonville, & Jarvik, 1985). In a
review of 14 empirical studies, McLean (1987) found that 52
percent of senile dementia cases were DAT.

The onset of the disease is described as “insidious"
(DSM III-R, 1987). In many cases, Alzheimer's is not
correctly diagnosed until the disease is in its later stages
(McLean, 1987; La Rue, et. al, 1985). The existence of
several diagnostic systems (e.g., DSM III—R, ICD-9, RDC,
Gustafson and Nilsson) is one reason timely diagnosis of the
disease is difficult. Each system uniquely defines the
longitudinal course, clinical features and laboratory
findings of the disease (McLean, 1987). As each diagnostic
systems defines aspects of the disease differently, it
becomes increasingly difficult to obtain a consensus

definition of Alzheimer’s. In general, however, Dementia of

the Alzheimer Type is:

The presence of Dementia of insidious onset and a

generally progressive, deteriorating course for which

all other specific causes have been excluded by the
history, physical examination, and laboratory tests.

The Dementia involves a multifaceted loss of

intellectual abilities, such as memory, judgment,

abstract thought, and other higher cortical functions,

and changes in personality and behavior (pp. 119-120,

DSM III-R, 1987).

Unlike MID, the progressive nature of DAT eventually results
in death. While a definitive diagnosis of DAT cannot be made
until post—mortum autopsy, the use of CT-scans and MRIs can
be used to distinguish MID. Frequently, however, cases of
dementia are referred to as DAT, even though formal diagnoses
have not been given.

This study was an attempt to identify and distinguish
persons with dementia in its early stages from those with
mild depression and from healthy individuals, using a test
of verbal memory, the Selective Reminding Task (Buschke,

1973). References in this text to ”dementia" concern the

permanent dementias, without exception.

D' . D I' and.!] l . , E'
More prominent than the lack of consensus on
definition is the inherent problem of identifying the
disease. Because DAT and permanent dementia involves a
chronic loss of "higher cortical functions", the clinical
features of the disease tend to be general and varied. Its
"insidious onset" and "generally progressive, deteriorating

course” enhance the possibility of overlooking the early

symptoms, making dating the onset even more difficult.
Changes caused by dementia (i.e. short-term memory loss,
changes in behavior) are often similar to those expected in
the normal aging process, again, making identification of the
symptoms arduous. In addition, the symptom cluster of
dementia overlaps with several other psychiatric diagnoses.
In particular, cognitive impairment and changes in
personality and behavior are also common to many other
diagnoses (McLean, 1987). This overlap further complicates
correct diagnosis as it decreases the specificity of the
diagnostic criterion. Although memory impairment is the
original presenting problem in most correctly diagnosed cases
of DAT (Kendrick, 1982), the impairment progresses subtly
which hinders identification of cognitive decline until it
has reached a severe level (McLean, 1987a).

In the literature an additional diagnostic label has
been utilized. The term "pseudodementia" is used to describe
the syndrome where "functional psychiatric illness" (La Rue,
et. a1, 1985; Wells, 1979) creates memory problems which
mimick dementia. Despite its widespread use, the diagnosis
of "pseudodementia“ has not been incorporated into DSM III—R.

A correct differential diagnosis between pseudodementia
and dementia is considered by some to be crucial. For
example, in cases of pseudodementia, since the cognitive
impairment is usually transient and treatable the memory
impairment which accompanies the disorder should disappear

upon remission of the disorder. In contrast, dementia is

still considered to be largely untreatable and deterioration
is generally progressive and steady: The memory impairments
which accompany the disease are also generally considered to
be irreversible (McLean, 1987). Hence, the different
diagnoses require radically different treatment plans. A
diagnosis of pseudodementia suggests psychotherapy or drugs
as the subsequent treatment plan, whereas the diagnosis of
DAT indicates a treatment plan which involves teaching coping
strategies to the victim and family members (McLean, 1987a).
Thus, according to this orientation, an expedient, correct
differential diagnosis is important, and the detrimental side
effects of diagnostic errors have been well documented (e.g,
Kramer, 1982; McLean, 1987).

There have been several attempts to provide
guidelines for distinguishing pseudodementia from true
dementia. 0f the various attempts, the criteria compiled by
Wells (1979) are considered the most representative (La Rue,
et. al, 1985; McLean, 1987). He delineates the differences
with regard to clinical course, symptoms and behaviors, and
cognitive dysfunction produced by the disorder. For
example, sudden onset of symptoms and rapid progression of
dysfunction are both indicative of pseudodementia. Although
memory loss and other cognitive dysfunction are present in
patients of pseudodementia, they are rarely considered the
presenting problem. In addition, pseudodementia patients
vehemently complain of their memory loss and are willing to

openly demonstrate it, whereas dysfunction is either

unnoticed by dementia patients or carefully concealed.
Actual performance on tasks is often inconsistent with
expectations, given the nature of the symptom complaints of
pseudodementia patients. For example, a patient who
complains of poor concentration may still do very well on a
task which requires concentration. Finally, other symptoms
which differentiate pseudodementia from dementia include,
complaints of memory loss for both recent and remote events,
loss of social skills, and an absence of lability (Wells,
1979).

Others argue that depression and dementia in
combination interact to produce a synergistic effect. Thus,
attempts to differentiate between the two are futile.
Instead of occupying their time distinguishing between
dementia and depression, researchers should be investigating
the clinical presentation that is the result of the
combination of the two phenomena (Salzman & Gutfreund, 1987).

Despite guiding criteria, diagnostic errors still
occur, as the features of pseudodementia vary on an
idiographic basis. As a consequence, pseudodementia is not a
singularly well-defined disorder. Instead, it consists of
several non-organic psychiatric disorders which may present
as dementia (McLean, 1987).

The disorder most commonly associated with
pseudodementia is that of depression (Wells, 1979; McLean,
1987). It is highly prevalent in the elderly population. In

fact, the two disorders are often presented in the literature

 

interchangeably even though to do so is an oversimplification
(La Rue, et. al, 1985; McLean, 1987). Nonetheless, the
prevalence of clinical depression in cases of pseudodementia
is high. In a review of empirical literature, McLean (1987)
estimates that depression is the cause of 80 percent of
pseudodemetia cases. This seemingly high estimate suggests a
significant overlap of the symptoms which define depression
and dementia. In fact, cognitive impairment, i.e. memory
loss, is often found in elderly depressived patients.
Similarly, depression is present in 15 to 30 percent of
dementia patients (McLean, 1987a). In addition, the
prevalence of depression in the elderly is disproportionately
high, with 10 to 15 percent of the geriatric population being
severely affected (La Rue, et. al, 1985).

That depression is prevalent in the elderly is not
surprising. In a society which places primary value on the
individual's ability to be independent, produce, and compete,
the average retired person does not fit the mold. Instead of
being able to take comfort in his ability to share his wisdom
and knowledge of years past with others, the older person has
only the bitter reality of the waning years ahead and the
knowledge that he is or is becoming the one thing society
devalues most - dependent. The onset of sad affect and
feelings of worthlesness are often accompanied by a decrease
in activity and general loss of interest. Lack of effort and
inattention to detail can contribute to memory loss. As a

consequence, depression and dementia are frequently compared

 

in the literature on the elderly. In particular, numerous
studies have investigated how the memory impairment in
dementia patients differs from that found in patients with

depression.

Mammandthelmumflmcessinguml

Studies of memory in the older adult have been
dominated by the information-processing model of memory.
This model assumes that: the individual actively
participates in learning and remembering, that analysis of
the quality and quantity of response patterns is informative,
and that the path of learning can be traced through several
hypothetical memory stages (Poon, 1985).

New information is originally registered in sensory
memory. Sensory memory is either visual or auditory. The
information is then held for storage in short-term (primary)
memory (STM), a limited-capacity store. Information produced
by STM is considered still "in mind” (Poon, 1985). Once
information is in STM one of two things can occur ~ either
the presentation of new information to STM erases the memory
traces of the original information or the information is
stored in long-term (secondary) memory (LTM). LTM has
unlimited storage space. The final memory stage is tertiary
(remote) memory in which remote, permanently stored
information is retained. Of all the memory stages, only the
functioning of LTM declines significantly with age (Poon,

1985). The decline in LTM manifests itself in the encoding

and retrieval of information.

Encoding is the process of storing information in
LTM. In general, it occurs either through the effects of
practice, i.e., repeating the information while it is in STM,
or through recognition as the information may already be
registered in long-term storage (LTS; Glanzer, 1972). The
act of recalling stored information is referred to as
retrieval. The ability to retrieve from LTS is assisted by
higher-order encoding or successful recall (Tulving, 1982;
Thompson, Henger, & Bartling, 1978). Similarly, forgetting
can be the result of an encoding deficit, a retrieval
deficit, or an interaction involving both (Poon, 1985). For
quantitative and qualitative analySis of memory patterns, a
procedure which divides the learning process into measurable
components is required. The Selective Reminding Task (SRT;
Buschke, 1973), a frequently used measure of memory

impairment, is such a procedure.

Th£_5£l££I11£ anindini Task and MQmQLx ImQainment

The SRT provides distinct information on LTS, STM, Long
term retrieval (LTR), list learning (Consistent LTR), and
item learning (Random LTR; Buschke, 1973 & Buschke & Fuld,
1974). In the administration of the SRT the subject is
instructed to learn a list of words (Buschke, 1973). The
words are presented to the subject at two-second intervals.
The subject is then asked to recall all the words in the list

in any order. After each trial, the subject is then reminded

 

10

of only those words which were not recalled on the
immediately preceeding trial. If a subject is able to recall
a word which was not presented on that trial, he must be
using retrieval from LTS, as "it [the item] was recalled even
though the presentation and recall of other items interfered
with the short-term retention of this item (p. 1021, Buschke
& Fuld, 1974)." If, however, recall of a word only occurs
after presentation, the subject is demonstrating STR (Buschke
& Fuld, 1974).

Once an item has been retrieved from LTS, it is
assumed that any subsequent inability to recall that item is
the result of retrieval failure, not retention failure or
loss from storage (Buschke & Fuld, 1974). This assumption
has received support from research in which subjects were
able to retrieve words without the aid of presentation, even
though they had been previously unable to recall the words
(Buschke, 1974; Buschke & Fuld, 1974).

The SRT also separates LTR into Consistent LTR
(CLTR) and Random LTR (RLTR). CLTR represents the number of
words which are consistently retrieved without presentation.
That is, a participant demonstrates CLTR when they no longer
require a reminder for a particular word. CLTR indicates how
much of the entire list the subject has learned. Random LTR
also represents the number of words retrieved without
presentation, however it indicates how many of the words have
been learned independent of the list. It is represented by

words which are committed to LTS, but the presentation of

11

which requires a reminder from the administrator of the SRT
(Buschke & Fuld, 1974). The consistency of retrieval which
is inherent in CLTR is indicative of an "organized retrieval
search" (Buschke, 1973). RLTR, however, with its inherent
inconsistent retrieval, indicates the absence of such
organization.

The number of words to be used on a list were never
specified by Buschke, but an evaluation of the SRT using a
mathematical learning model for patients with Dementia of the
Alzheimer's Type (DAT) and controls indicates list length
should be 10-12 words for patients with severe DAT and 15-20
words for controls and patients with mild DAT. The
evaluation also found that the number of trials is
theoretically optimal if it is greater than 10, but
realistically optimal if the task involves between five and
10 trials (Kraemer, Peabody, Tinkleberg, & Yesavage, 1983).

Despite its widespread use, the efficacy of the SRT
is a controversial issue. Some attempts to obtain normative
data have produced discouraging results. For example, when
the four different lists of the SRT were compared, one form
(Form 1) was found to be significantly more difficult for
normal college students than the other three forms (Hannay &
Levin, 1985). Masur, et. al. (1989), however, found no
differences in performance among the four forms using an
elderly sample. None the less, although normative findings
have been published in recent years, those findings

concentrate on only Form 1 of the test. Morgan (1982)

12

produced normative data for children between 5 and 8 years of
age. Banks, Dickson, and Plasay (1987) produced preliminary
normative findings for 60 healthy elderly subjects, and
Larrabee and his associates recently published normative data
on the SRT using 271 participants. The normative findings
are grouped into seven age groups ranging from 18 to 91 years
of age (Larrabee, Tahan, Curtiss, & Levin, 1989). In
addition, the procedure is not a standardized test (Loring &
Papanicolaou, 1987).

Kraemer, et. a1. (1983), present several
explanations for the lack of normative data on the SRT. They
maintain that parameters such as number of words in a list or
number of trials in a task have not been specified. In
addition, the type of list used and the scoring procedures
have never been standardized. Finally, word familiarity and
difficulty of the task are important intangibles when
administering the task, thus each administration needs to be
somewhat personalized.

Bishop, Dickson, and Allen (1988) conducted a study
with sixty college students as subjects. The subjects were
divided into four groups on the basis of intelligence (low
average, average, high average, and superior). After
administering the selective reminding task, the results
indicated that intelligence is related to performance on this
task. Individuals in the low average intelligence group
performed signicantly poorer than subjects from the high

average and superior intelligence groups on all aspects of

13

the task. These results suggest that intellectual level is
correlated with performance on the SRT, since being of low
average intelligence, in itself, is not an indicator of
memory deficits. Patients with premorbid low average
intelligence risk a false positive result from the SRT.

However, Ruff, Light, and Quayhagen (1989), in a
study with 392 participants found no relationship between
HAIS-R VIQ and performance of the SRT. Also, other studies
have found no relationship between education and SRT
performance (Masur, et. al, 1989; Ruff, et. al, 1989; Banks,
et. al, 1987). Another study found that age did not have a
significant effect on individual’s performance in the SRT
(Masur, et. al, 1989). This study, however, sampled a
limited population (75-85 years old). One should be
cautious, therefore, of generalizing from these findings.

In their critique of the SRT, Loring and
Papanicolaou (1987) point to Buschke's distinction between
long-term storage and retrieval as a methodological
shortcoming. They argue that Buschke's assertion that a word
has entered long—term storage once it has been recalled on
two consecutive trials is arbitrary, and requires that any
subsequent failure to recall is a retrieval failure. This
does not account for the possibility that words may have been
stored in a degenerate form. The eventual complete encoding
and consistent retrieval are possible only after repeated
presentations by the examiner. Hence, according to Loring

and Papanicolaou, the operational definitions of storage and

14

retrieval are incomplete.

The results of one study points toward the presence
of practice effects and low test—retest reliabilities
(ranging from .45 to .85; Hannay & Levin, 1985). Another
study, however, found high test-retest reliabilities,
especially for LTR (.837), recall (.892), and CLTR (.918;
Masur, et. al, 1989). Loring and Papanicolaou (1987) argue
that practice effects suggest the SRT may measure the ability
to learn how to execute a high ordered cognitive task, not
just the ability to remember. The inability to learn could
be partially responsible for a patient's poor performance on
the procedure. As a consequence, Loring and Papanicolaou
assert that “SR should not be used clinically as the sole
measure of verbal memory" (p. 348). However, the study
used healthy college students as subjects and, as the authors
of the study point out, their performance may not be
indicative of the unhealthy population which usually partakes
in the SRT (Hannay & Levin, 1985). For example, some studies
report the absence of practice effects for clinical patients
participating in the SRT (Peters & Levin, 1977; Peters &
Levin, 1979).

Several studies have found that the selective reminding
procedure, in general (Heingartner, Kaye, Smallberg, Ebert,
Gillin, & Sitaram, 1981), and the SRT, in particular
(Larrabee, Largen, & Levin, 1985), to be very sensitive to
the presence of DAT. For example, Larrabee, et. a1. (1985),

found that the SRT was the most sensitive measure of DAT

 

15

among several cognitive and memory measures (i.e. WAIS and
WMS subtests). When the predictive value (sensitivity) of
the SRT was 100 percent, the common error (specificity) was
only one percent. In another study, an individual’s LTS and
LTR were found to have a predictive value in differentiating
between elderly with DAT and healthy elderly (Masur, Fuld,
Blau, Thal, Levin, & Aronson, 1989).

With regard to the differences between memory
impairment in dementia patients and depressed patients,
several quantitative, qualitative, and theoretically—based
differences exist. Memory loss in dementia patients is
quantitatively more severe and qualitatively more diffuse
than in depressed patients (Miller & Lewis, 1977; La Rue,
D’Elia, Clark, Spar, & Jarvik, 1988). For example, La Rue,
et. al (1988), administered a neuropsychology battery,
including a selective reminding procedure, to elderly
participants who were healthy (N=10), participants diagnosed
as demented (N=10) as well as to participants diagnosed as
depressed (N=10). They found that demented elderly scored
significantly worse than depressives on measures of storage,
retrieval, and consistent retrieval. Similarly, depressives
scored significantly worse than healthy controls on measures
of retrieval and consistent retrieval.

In another study (Hart, Kwentus, Hamer, & Taylor,

1987) 15 patients with mild DAT, 14 depressed patients, and

 

16

16 healthy controls were administered the SRT with low and
high imagery words. The measures of total recall, CLTR, and
LTS scores of the dementia subjects were all significantly
lower when compared to both depressed patients and normal
controls, whereas depressives were signficantly lower on
measures of total recall and CLTR when compared to normal
controls.

Memory impairment reported by DAT patients and
depressed patients also differs in its theoretical
underpinnings. The determinants of memory failure in
dementia patients result in a decline in functioning in all
areas of memory (Weingartner, Grafman, Boutelle, Kaye, &
Martin, 1983). In contrast, memory loss in depressed
patients is believed to stem from an inability to execute
effortful processes. Effortful processes (i.e. memorization)
require the expenditure of attention and effort. As a
consequence, they use some of the limited resources available
for processing information (Hasher & Zacks, 1979). Some
researchers have found that depression further limits the
resources available for processing information, as depressed
patients showed greatest cognitive impairment in tasks which
required sustained effort (Cohen, Weingartner, Smallberg,
Pickar, & Murphy, 1982). In addition, patients, during
depressive episodes, change how they process information.
Processing tends to be weak and incomplete during these
episodes (Weingartner, Cohen, Murphy, Martello, & Gerdt,

1981).

17

W

Often times depression in the elderly is masked by
apparent symptoms of dementia. Severity and pervasiveness of
memory loss, seems one way of differentiating between the
two. With even mild dementia, impairment of memory is more
severe and comprehensive memory than with depression (Hart,
et. al, 1987). One explanation of this difference in
impairment is that depressed individuals do not have the
resources to execute more effortful processes, even though
they have the premorbid capability to do so (Cohen, et. al,
1982), whereas demented patients suffer from a general
biologically-based breakdown of memory functions.

The main focus of this study is to examine within
an elderly population the effects of mild dementia and mild
depression, and how they differ from each other with regard
to encoding and retrieval processes. The approach of this
study is unique in that the participants in the dementia
group have been screened for mild dementia using a brief
neuropsychological test battery. No formal diagnses were

given. Specifically, it is hypothesized that:

I) Subjects with mild dementia, as defined by a borderline or
positive score on a neuropsychological test battery (SDAT-

battery, Storandt, Botwinick, Danziger, Berg, & Hughes, 1984)
will perform significantly worse on measures of total recall,

long term storage (LTS), long term retrieval (LTR), and

18

consistent long term retrieval (CLTR) when compared to both

subjects with mild depression and healthy controls.

II) Similarly, subjects with mild depression, as defined by a
score of 10-20 on the BDI, but no dementia will perform

significantly worse on measures of total recall, LTS, LTR,
and CLTR when compared to healthy controls due to the

formers' inability to execute effortful processes.

III) The ratio CLTRzLTR will be significantly higher for
depressed subjects when compared to participants with mild
dementia, and significantly different from the healthy group.
Depressed persons have difficulty with memory processes which
are effortful. Storing and retrieving new information
requires more effort than consistently retrieving the same
previously stored information. In addition, retrieving
previously stored information requires an organized retrieval
search which depressed persons would seem more capable of
executing than persons with dementia. Therefore, it would
seem that of the responses from LTR, depressed individuals
would have a higher proportion of CLTR responses than

subjects with mild dementia.

19

E l' . l

Participants were 12 elderly persons screened for
mild DAT, 14 aged with mild complaints of depression, and 54
healthy elderly individuals. They ranged in age from 55 to
91 (H = 70.31 years, SD = 8.75) and education from 8 to 28
years (H = 15.80, SD = 3.85). Of the 80 participants, 54
were women and 28 were men. Characteristics of the sample
are presented in Table 1.

Participants were retirees from a local university. 183
individuals were interviewed and they were grouped based on
their performance on a battery of tests. The DAT subjects
scored borderline or positive (x _; -0.500) on a brief
battery developed for the differentiation of DAT from healthy
individuals (Senile Dementia of the Alzheimer’s Type {SDAT} —
Battery; Storandt, et. al, 1984). Participants were placed
in the depressed group if their score on the Beck Depression
Inventory was between 10-20 (Beck & Beamesderfer, 1974) and
their score on the SDAT-battery was below the borderline
level. Individuals whose score was below the borderline
level on the SDAT-battery and below 5 on the BDI were placed
in the healthy control group. Individuals who scored

positively on both measures were dropped from the study.

20

 

Group N Age Educx Gender

M SD M SD Females Males
5;};2EI;’”“—’I§’_§ZTZ§‘“§TSE““IZTIQ""§T;2 """"" 9 ” 3‘
Depression 14 70.50 7.86 15.43 4.31 8 6
Healthy 54 70.26 5.50 16.43 2.83 37 17
Synergistic 7 69.22 6.55 11.17 3.60 7 0
Total Sample 87 70.78 6.36 15.60 3.44 26 61

* Three participants did not indicate the number of years
they received formal education. Each was from a different
group (Dementia, Healthy, and Synergistic). Thus, the
means and standard deviations for each of these groups, as
well as the Total Sample, were calculated using a smaller

N.
Table 2. Screening Characteristics of Sample by Group
8:33; """"""""" Q """"""""" EB} """""""""""""" £52? ”””””””””
M SD M SD
B;;;;ZZ;"'"_’—IE """" ETEE""""ZTZZ”””’”‘T§I""F“TEE ________
Depression 14 12.3 2.99 —1.99 1.39
Healthy 56 2.57 1.82 ~2.40 .22

Synergistic 7 14.43 1.81 .32 .99

*_*n—___—_—~_-———_—*m—_—_-*-u———_——fl_

21

Measures

Senile-Dementia of the Alzheimer’s Type Battery (SDAT
Battery). The SDAT battery is a set of four psychological
tests. Its purpose is to differentiate persons with SDAT in
its early stages from normal older adults. The four tests
were selected from a variety of tests based on correlational
and discriminant analyses. The four subtests are the logical
memory and mental control subtests of the Wechsler Memory
Scale, Form A of the Trailmaking Test, and word fluency for
letters S and P. The score of each subtest is individually
multiplied by a coefficient supplied by Storandt, et. al.
(1984). The products are summed together with a constant,
also supplied by the authors, to detect the presence of DAT.
In one study the SDAT battery correctly distinguished 98% of
patients with DAT and healthy older persons matched for age,
sex, and social position. Only two false alarms were
reported (Storandt, et. al, 1984).

Beck Depression Inventory (BDI). The BDI is a self-report
measure with a multiple-choice format. It purports to
measure the presence and severity of depression in children
and adults. It contains 21 items, each of which assesses a
specific feature of depression by giving it a weight of zero
to three points. Reliability and validity studies conducted
in varied settings and populations strongly support the BDI
as a measure for assessing depression. It has also received
strong support from cross-validation studies (Stehouwer,

1985).

22

Selective Reminding‘Task (SRT). In addition to studies
involving memory and the different dementias (e.g., Buschke,
1974, Caine, Ebert, & Weingartner, 1977; Fuld, Katzman,
Davies, & Terry, 1977; Grady, Haxby, Berg, & Rapoport, 1987),
the SRT has been used in research on memory and the efficacy
of treatment for hyperactive children (Zametkin, Karoum, &
Rapoport, 1987), the effects of chronic marijuana use (Page,
Fletcher, & True, 1988), and the effects of certain drug
treatments on memory (Shaw, Stokes, Mann, & Manevitz, 1987).
For a more detailed discussion of the SRT, please see the
subsection entitled "The Selective Reminding Task and Memory

Impairment."

Procedure
The SDAT-battery, the SRT, and the BDI were administered

as part of a larger study designed to assess an individual's
overall coping skills with the aging process. Form letters
were sent to retirees from a local university requesting
their participation in a study investigating how elderly
people cope with the aging process. Individuals who wanted
to participate called the coordinator of the project; nearly
10 per cent of those sent letters responded. The coordinator
of the project then referred their name to an examiner. All
examiners had received training prior to interviewing
subjects. Participants were not paid, however, they were
promised a ”feedback session" at which time the interviewer

would inform the participant of the quality of their overall

23

functioning as compared with other elderly.

The entire interview process required between
one-and-a-half and two-and-a-half hours. The process began
with a semi-structured interview. Half way through the
interview questions concentrated on the individual's
perception of their memory. At this time the SDAT-battery
was administered. Completion of the battery required
approximately ten minutes, after which the semi-structured
interview was completed. After the interview the SRT was
administered using ten trials. The SRT required another ten
minutes. After completion of the SRT, the participant were
given the BDI and 881. Each self-report measures required 15
to 20 minutes to complete. Five to seven working days after
the interview session the participant was contacted to
schedule their feedback session. All individuals who were

interviewed received feedback.

24

Results

All analyses were conducted with the use of
SESS;X_user2S_Quide_;_lhird_Editien.(1988).

Initially, multivariate analyses of variance were
conducted on five dependent variables, recall, LTS, LTR,
CLTR, and CLTR:LTR. In the cases of significant findings,
however, this method of analysis was not linearlly
interpretable. As a consequence, univariate analyses were

also conducted.

HEDDIheses

Hypothesis 1. Statistical analyses of the data only
support a portion of the first hypothesis. It was predicted
that individuals in the dementia group would score
significantly less on all variables of the SRT than those
participants in the depression and healthy groups. A
multivariate analysis of variance conducted on all the
variables indicated significance only for the number of words
recalled {F(2,77) = 4.32447, p < .05; please see Table 2}.
That is, the scores of each variable were analyzed across the
tflaree groups. Only in the case of recall did the scores
differ from each other, depending on the group to which the
participant belonged.

Univariate analyses revealed there were no significant
differences between the dementia group and depression group.

However, significance was found between the dementia group

25

Table 3. Means and Standard Deviations for all groups,
across variables
--------- +-——-——-----+——--------—+----—-——---—-+-----—----——-
Variable : Dem(N=12) : Dep(N=14) :Healthy(N=54): Syn(N=7)

: M : SD : M : SD : M : SD : M : SD
--------- +-—---+—----+-----+—---—+-—-—--+------+------+------
Recall(a):81.92:14.88:85.84:14.98: 72.78: 12.01: 58.88:20.43

I I I I I I I I
LTS(b) :44.50:l8.58:48.14:22.38: 58.09: 21.13: 38.43:28.01

I I I I l I I I

I I I I I I I I
LTR(c) :37.33:18.82:40.29:20.18: 48.44: 19.98: 29.88:28.71

I I I I I I I I
CLTR :21.75:19.19:23.38:15.89: 27.48: 17.92: 17.88:23.58
CLTR/LTR : .50: .28: .53: .18: .52: .21: .45: .30
--------- +-—---+—--——+-----+-----+—----—+-----—+-----—+---——-
(a) MANOVA indicated significant differences across all

(h)

(0)

groups at .05 level. ANOVAs revealed significant
differences between Dementia group and Healthy group

(p < .05), Depression group and Healthy group (p < .10),
and Synergistic group and Healthy group (p < .05).

MANOVA of all 4 groups indicated significant differences
across all groups at .10 level. ANOVAs revealed
significant differences between Dementia group and
Healthy group (p < .10) and Synergistic group and Healthy
group (p < .05).

MANOVA of all 4 groups indicated significant differences
across all groups at .10 level. ANOVAs revealed
significant differences between Dementia group and
Healthy group (p < .10) and Synergistic group and Healthy
group (p < .05).

28

Univariate analyses revealed there were no significant
differences between the dementia group and depression group.
However, significance was found between the dementia group
and control group for recall {F(1,84) = 7.327, p < .05;
please see Table 2}. That is, the number of words recalled
by a subjects in the control group was significantly greater
than those recalled by subjects in the dementia group.
Analysis of all the other variables, LTS, LTR, CLTR,
CLTR/LTR, indicates that the range of scores on these
variables from the dementia group and control group overlap
to such a degree that they are indistinguishable, although
there was a trend toward significance for LTS and LTR
{F(1,84) = 3.108, p < .10 and F(1,84) = 3.077, p < .10,
respectively; please see Table 2}. In addition, no
significant differences were found among these variables

between the dementia group and the depression group.

Hypothesis II. The second hypothesis predicted that the
scores of the depression group would be significantly

lower than the healthy group on all variables of the

SRT. This hypothesis was not supported as no significant
differences between the depression group and the control
group among the variables. That is, there was overlap of the
scores from the dementia group and those from the healthy
group for all variables. However, a trend toward
significance was discovered for the difference between the

depression group and the control group for recall {F(1,88) =

27

1.537, p < .10}, in the expected direction (Please see Table

2).

Hypothesis III. The final hypothesis predicted that the
ratio of CLTR:LTR could be used to differentiate among the
groups. This is a ratio of words the recalled through an
organized search compared to the total number of words
retrieved from long-term memory (LTR). Specifically, it was
predicted that the porportion of CLTR:LTR would be
significantly greater for the depressed group, when compared
to the dementia group. It was also predicted that the
CLTR:LTR ratio of the depression group would be significantly
different from the healthy group, although direction was not
predicted. Again, this hypothesis was not supported, as no
significant differences in the CLTR:LTR variable were found
among the groups (please see Table 2).

In addition, several ad hoc analyses were conducted.

AdHQc—Analxses

First, it was observed that the error term for CLTR:LTR
was considerably lower than those for the other variables.
One possible explanation for the low error term was that the
two variables approximated each other in value. If this were
so, one would expect little variance. A correlation analysis
was conducted between CLTR and LTR and was found to be highly
significant (r = .9041, p < .001; please see Table 3),

indicating that the values of the two variables are indeed

 

28

Table 4. Correlation of CLTR and LTR

—-—_-—-————_——-------——--—-——------——---—-—-----——---——_——---
-——-_—-_—--u-—-—-----——-——----———————-———-—-——_-—-------—----

29

very similar.

Also, it was decided to gain further information about
participants who tested positive for both mild dementia and
mild depression. Consistent with other studies (Salzman &
Gutfreund, 1987), it was speculated that the presence of both

depression and dementia in these individuals would create a

synergestic effect in which this group's scores on recall,
LTS, LTR, CLTR, and CLTR:LTR, would be less than the other
three groups.

A fourth group was created composed of seven subjects
whose scores were drawn from the data pool. These
participants tested positive for both mild dementia and mild
depression. A multivariate analysis of the four groups
indicated significance for recall {F(3,83) = 4.5993,

p < .01}, and a trend for LTS {F(3,83) = 2.48518, p < .10},
and LTR {F(3,83) = 2.55791, p < .10; please see Table 2}.
Univariate analyses reveals that this new group differs
significantly from the control group on measures of recall
{F(1,59) = 9.108, p < .05}, LTS {F(1,59) = 4.985, p < .05},
and LTR {F(1,59)=4.985, p < .05}, all in the expected
direction. However, the synergistic group did not differ
significantly from any of the other groups (Please see Table
2).

Next, multivariate analyses were conducted on the data
with age, education, and gender of the participants as
covariates. Initially, regression analyses were conducted on

each covariate to determine whether it was a reliable

 

30

predictor of the variable. Then, analyses were conducted to
evaluate the presence of a significant interaction between
the covariate and the factor (group). The presence of an
interaction suggests that changing the covariate effects the
dependent variables differently in each group. If an
interaction effect was present a final analysis was conducted
to determine how the covariate effects the variable within
the groups.

Age was found to have no predictive value on any of the
four variables (please see Table 4). There was, however, a
significant interaction effect between age and group
along the CLTR:LTR ratio {F(3,79) = 3.87, p < .05; please see
Table 5}. This indicates that age has a different effect on
the CLTR:LTR ratio, depending upon the group. An age within
group analysis of CLTR:LTR {F(4,79) = 2.94, p < .05; please
see Table 8} reveals that age effects the variable, CLTR:LTR
differently depending upon the group. Examination of the
regression line for each of the four groups indicates
that an interaction effect is present in the depression group
(p < .05) and the healthy group (p < .05), but not the
dementia or synergistic groups (please see Table 7). In
addition, the slopes of the regression lines (see Table 7)
indicate the, when present, interaction has a different
effect for each group. For the healthy group, as age
increases the CLTR:LTR ratio declines. In the depression
group, however, as age increases, CLTR:LTR also increases.

Regression analyses indicated that education is not a

 

31

Table 5. Regression Analyses of Age, Education, and Gender
as Covariates

Variable Sq Mul R Mul R Hyp MS Error MS F Sig of F
-Covariate

 

Recall
Age .004 .011 84.073 188.278 .340 .581
Educ .015 .123 231.444 191.309 1.210 .275
Gender .125 .354 1937.890 185.428 11.715 .001
LTS
Age .000 .011 4.758 471.490 .081 .920
Educ .003 .053 104.882 475.245 .220 .840
Gender .087 .259 2591.430 439.948 5.890 .017
LTR
Age .001 .037 48.278 420.803 .110 .741
Educ .003 .055 100.389 428.223 .235 .829
Gender .083 .288 2888.494 388.188 7.428 .008
CLTR
Age .005 .087 124.728 338.159 .371 .544
Educ .001 .029 22.731 342.545 .088 .797
Gender .084 .290 2322.802 309.353 7.509 .008
CLTR/LTR
Age .002 .041 .007 .050 .140 .709
Educ .004 .084 .018 .050 .325 .571
Gender .073 .270 .302 .048 8.447 .013

D.F. for age and gender was (1,82).
D.F. for education was (1,79).

32

Table 8. Univariate Tests of Interactions (3,79)

Variable Hyp. MS Error MS F
—Interaction
Recall
Group x Age 340.85 182.49 1.87
Group x Educ 881 35 171.97 3.98*
Group x Gender 318 30 181.80 1.97
LTS
Group x Age 857.83 484.41 1.42
Group x Educ 948.45 458.57 2.07
Group x Gender 182.30 448.39 0.41
LTR
Group x Age 747.25 408.20 1.83
Group x Educ 712.98 414.90 1.72
Group x Gender 240.77 389.82 0.82
CLTR
Group x Age 852.78 318.54 2.89
Group x Educ 274.98 345.21 0.80
Group x Gender 319.47 309.10 1.03
CLTR/LTR
Group x Age 0.48 0.05 3.88*
Group x Educ 0.08 0.05 1.22
Group x Gender 0.10 0.05 2.22
* Sig at p < .05
D.F. = 3,79 for Group x Age
D.F. = 3,78 for Group x Education
D.F. = 2,80 for Group x Gender

 

 

33

Table 7. Age within Group Analysis of CLTR:LTR

Source of SS DF MS F Sig of F
Variation
GEELESI§;;EQQQE”'£'86"""$§ """" 65 """"""""""""
Age within Group 54 4 13 2 94 025
Group 54 3 .18 3 91 012

 

Table 8. Significance of Regression Lines in Age by Group
Interaction of CLTR:LTR

Group N Corr R—squared Sig Slope
6;;;523;"‘I§ ”””” ITEQ'"""766"""""T515 ””” IETBB """"
Depression 14 .54 .29 .048 0.01
Healthy 58 -.34 .11 .014 —0.01

Synergistic 7 .52 .28 .228 0.02

34

valid predictor of any of the four variables (please see
Table 4). An interaction effect between education and group
was discovered along the recall variable {F(3,78) = 3.98,
p < .05; please see Table 5}. An education within group
analysis of recall {F(4,78) = 3.31, p < .05} also suggests
that the effects of education vary across the groups (please
see Table 8). Examination of the regression line for each
group reveals that the effects of education on recall are
significant only in the presence of depression (p. < .05;
please see Table 9). In the depression group, as education
increases the number of words recalled increases (slope =
.01; please see Table 9).

Analyses of gender revealed that it has significant
effects on all the dependent variables: recall {F(1,82) =

11.71, p < .001}, LTS {F(1,82) = 5.89, p < .05}, LTR {F(1,82)

7.43, p < .01}, CLTR {F(1,82) = 7.51, p < .05}, CLTR:LTR {F

8.45, p < .05; please see Table 4}. Women performed better

than men on every variable (please see Table 10).

35

Table 9. Education within Group Analysis of Recall

Source of 88 DF MS F Sig of F
Variation
61313323335"-"iiéééféé"'56—’33]; """"""""""
Educ within Group 2248.81 4 584.20 3.03 .022
Group 2509.13 3 838.88 4.51 .008
Table 10. Significance of Regression Lines in
Education by Group Interaction of Recall
GEES; """""" ii """ 63;; '''' 12133;; """" £1; ———— £135; """"
BQQQSEEJ’E ””” IT£;""’"T6§"""""SETMIITEI """
Depression 14 .85 .42 .029 2.28
Healthy 58 -.14 .02 .309 —0.85

Synergistic 7 .52 .27 .231 -0.00

38

Table 11. Performance on Dependent Variables by Gender

ESE}; """"""" £3.33; """"""""""""" 12;; ------------------
M SD M SD

RESET-"mEZFQm-‘IETE?"""FIFE'm—IQTQE ''''''''''

LTS 48.98 22.53 58.10 21.37

LTR 40.02 21.26 48.59 20.53

CLTR 22.31 18.07 29.70 18.37

CLTR:LTR .47 .20 .55 .22

37

The results of this study indicate that only the recall
variable can be used to gain information regarding the
identification and differentiation of memory loss. This
finding is consistent with an earlier study which found that
the total number of words recalled and CLTR are more
sensitive discriminators of DAT than the WAIS and other
cognitive measures (Larrabee, et. al, 1985). It is also
consistent with a recent longitudinal study in which 385
nondemented voluntary subjects were administered the SRT.
Thirty-six of these participants were eventually diagnosed
with dementia at which time their performances on the SRT one
to two years prior to diagnosis were compared with those of
the healthy participants. Of all the variables on the SRT,
recall was found to have the greatest predictive value
(Masur, Fuld, Blau, Crystal, & Aronson, 1990).

Even though an individual's recall score can distinguish
a healthy participant from an impaired participant, it does
not distinguish between those that are in the dementia group
and those within the depression group. In addition,
predicting whether a participant is healthy or impaired using
the recall score will not always be accurate, as there was
only a trend toward significance between the depression and
control groups. If this trend were significant, a
participant's recall score would be a more accurate

distinction between groups of healthy and impaired

38

individuals.

A trend toward significance was also discovered between
the dementia group and control group for LTS and LTR. If
this trend were statistically significant, these variables
would also be viable options for distinguishing between

impaired and healthy individuals. However, similar to the

recall variable, LTS and LTR could not specify from which
impairment an individual suffers.

The third hypothesis, that the ratio of CLTR:LTR would
be significantly greater for depressed subjects than
participants with mild dementia, was not supported.

It was suggested by this author, that the ratio would provide
more information as to a participant's pattern of retrieving
information. Specifically, it was expected that of the words
regained from long term memory depressed individuals would
retrieve a higher porportion of words using an "organized
retrieval search" (CLTR) than participants with mild
dementia. A correlational analysis of CLTR and LTR was
conducted and found to be highly significant indicating that
CLTR and LTR are closely related. Thus, with knowledge of
the value of LTR, one could predict the value of CLTR fairly
accurately, and visa versa.

In review, Buschke and Fuld (1974) maintain that LTR is
an individual's ability to retrieve words from long term
storage. LTR can be simplified into two other variables -
CLTR and RLTR. CLTR represents an individual's ability to

consistently retrieving words without presentation and is

39

indicative of how much of the entire list has been learned.
RLTR indicates an individuals ability to retrieve words from
LTS with the aid of a reminder and represents how many words
are learned independent of the list. The value of LTR equals
the sum of CLTR and RLTR.

The significant correlation between CLTR and LTR

indicates that the two values approximate each other. As a
consequence, one can assume that there is very little
variability in the value of RLTR. These findings not only
question the value of the CLTR:LTR ratio, they also suggest
that LTR, CLTR, and RLTR measure the same phenomenon. Future
studies should consider executing correlational analyses of
these variables; if such a finding were repeated, it would
indicate that using all three variables is unnecessary.
Other studies (Salzman & Gutfreund, 1987) have reported
that the presence of both depression and dementia in
individuals with both mild depression and mild dementia
created a synergistic effect. This study offered tentative
support for this finding. In support of the "synergistic"
theory, this study found that the value of the variables
recall, LTS, and LTR, were all significantly smaller in this
synergistic group when compared with the healthy group. In
addition, brief examination of the means of all five
variables reveals that, without exception, the synergistic
group produced the lowest scores of any group. Once again,
however, these scores did not differ significantly from the

other experimental groups. Certainly, if a synergistic

40

effect were present one would expect that differentiating the
mixed group from the other experimental groups would be
easier. It would appear, however, that while the scores are
lower for the synergistic group, the differences are not
great enough for significance. One possible expalanation for
this is the small number of participants in the synergistic
group (7). Difficulties in sampling, including sample size,
are discussed in more detail later.

The analyses of age, education, and gender, as
covariates does not offer much additional information. Age
appears to have no significant main effects on the variables.
This finding supports and expands on the earlier findings of
Masur, et. al. (1989), as a wider range of age was sampled in
this study (range of 55-91 years old as compared to 75—85
years old).

An interaction effect was found with CLTR/LTR, only.
Further analysis revealed that the interaction effect was
present in the depression and healthy groups. In addition,
the interaction affected these groups in opposite ways. In
the depression group the relationship was positive, while it
was inverted in the healthy group. The interaction is
unusual as one would expect the covariate to have a uniform
effect across all groups. The heterogeneity could be due to
chance. The validity of CLTR:LTR as a variable has already
been discussed. If the heterogeneity were due to error, one
would want to reconsider the possibility that the ratio of

CLTR:LTR is not a valid measure.

41

Another potential explanation is that CLTR:LTR does,
indeed, measure a phenomenon unique to the other dependent
variables. This phenomenon would be susceptable to changes
in the age of the participant when the participant is
depressed or healthy, but not demented. The efects of the
healthy group lend credence ot the theory that memory loss is
an age—related phenomenon that occurs in healthy elderly, and
not always a dementing process. However, the effects of age
on the depression group are suspect. It would seem to make
the statement: In the presence of depression, as an
individual gets older, a higher porportion of all the words
that person can recite are retrieved via an organized search
pattern. This statement is counterintuitive. One would
expect that, if there were any interaction it would be as age
increases performance on the task would decrease, regardless
of the presence of depression. Conceptually, the phenomenon
being measured is obscure. As a consequence, the former
rationale, that the heterogeneity of variance is due to
chance and that CLTR:LTR is not a valid measure is the
preferred explanation. Before any conclusions are drawn,
however, this finding would have to be replicated. If chance
is the source of the variance, one would expect future
studies to not produce similar findings.

Education appears to have no main effects on the
variables. A finding which is supported by earlier studies
(Masur, et. al, 1989; Ruff, et. a1, 1989; Banks, et. al,

1987). An interaction effect between education and group was

 

42

discovered, however. It seems that in the presence of
depression, as education increases, the number of words
recalled increases. None of the other groups appear
susceptable to this interaction. This finding is also
difficult to explain. One would expect homogeneity across
the groups, and there is no apparent explanation as to why
the presence of depression facilitates this interaction.

One possibility is that education does effect
an individuals ablility to recall words. Individuals with
dementia are not effected by education because the dementing
process does not discriminate by education. For this
hypothesis to be valid, however, one would expect an
interaction effect in the healthy group also. The only
apparent valid assumption is that this heterogeneity was due
to chance. This finding is worthy of investigation in future
studies.

Gender appears to have a main effect on all the
variables. Women out-performed men on every measure of
memory. It could be that women have better memories than
men. A more likely reason for this main effect, however,
may be the disproportion of female subjects to male subjects.
Overall, there are twice as many female subjects as male
subjects, and in the synergistic group, all seven
participants are female.

According to these findings, among all the variables
made available by administering the SRT, only the overall

number of words recalled (recall) provides consistent

43

information about the subjects. And the amount of
information that can be provided by the recall variable is
also limited. Although a subject’s recall score can be used
to indicate whether the person is healthy or impaired, it
cannot distinguish whether the individual's score is low

because of dementia, depression, or a combination of the two.

In addition, the group score for healthy individuals and
depressed individuals overlap, so that a person's score may
indicate depression, even if that person is supposedly
"healthy". The opposite scenario is also possible. Thus,
even distinguishing between healthy and unhealthy individuals
based only on the total number of words recalled is less than
perfect.

There are two possible explanations as to why, in this
study, the SRT has not proven to be a viable predictor of a
participant's overall functioning. First, there is a
limitation in the sample population used in this study. Of
the 87 subjects tested in this study, only 33 could be placed
in one of the experimental groups, with twelve in the
dementia group, fourteen in the depression group, and
seven subjects in the synergestic group. The low number of
subjects in the experimental groups requires greater
differences in order to achieve significant results.

Further, sampling difficulties exist in the gender breakdown
of this subject pool. As mentioned previously, twice as many
women as men were tested for this study, and one of the

comparison (ad hoc analysis) groups contains no men. Future

44

studies using the SRT should take these sampling difficulties
into consideration, though it is well known that women have a
longer lifespan than men.

Another potential explanation for the present findings
in this study may be the difficulty level of the SRT. Many

participants, even those who were placed in the control

group, commented on the difficulty of the test. If the SRT
is too difficult for this population, one would expect a low
ceiling effect. This effect will truncate the range of
scores, making it more difficult to have scores from the four
groups which do not overlap. Therefore, the difficulty of
the SRT may have caused the scores to group together, making
it extremely difficult to achieve significant results.

To the credit of the SRT, it does not appear that
education or age have a significant impact on the subject's
performance.

While this study is a preliminary investigation, it has
provided us with many suggestions for future studies
involving the SRT and its ability to distinguish between
depressed, demented, and healthy individuals.

First, it is recommended that a larger and more evenly
distributed sample be used. As mentioned previously, the
small number of impaired individuals in this study required
greater differences in order to obtain significant findings,
as does the skewed gender distribution.

On the other hand, considering that this sample was

drawn from an overall population of "able elderly" it may be

45

that this population is more homogeneous than we anticipated.
Perhaps the impact of depression and memory impairment is
less evident than the media and other publicists suggest.

Further, the findings of this study indicate that the
scores of the different groups overlap, also affecting the
findings. This issue could be addressed in one of several
ways. One could use an easier SRT, thereby circumventing the
hypothesized ceiling effect found in this study. Kraemer,
Peabody, Tinkleberg, and Yesavage (1983) recommend using
lists that are 15-20 words in length with controls and
patients with mild DAT to avoid the ceiling effect. Although
this would not make the SRT easier for the participant, it
should allow for a wider range of scores.

Currently, the words on the SRT are chosen because they
are unrelated and, therefore, difficult to "chunk" (Buschke,
1973). However, using lists which contain some related words
would provide more information as to how individuals in the
three groups code and retrieve words, while also making the
SRT easier for the participant, thereby expanding the
potential range of scores. In addition, using the SRT with
delayed recall and delayed recognition has been found to
successfully discriminate demented elderly from normal
elderly (Branconnier, Cole, Spera, & DeVitt, 1982). Perhaps
these methods would have equally high discriminative validity
in differentiating memory loss due to dementia
from memory loss due to depression.

Another method future studies can use to avoid

48

overlapping of scores is to define the groups more strictly.
For example, mild dementia in this study was defined by a
borderline score, whereas future studies may wish to use a
more conservative cutoff score. Similarly, future studies
may wish to use individuals who test positive for a more
moderate to severe depression. More stringent definitions of
the groups would decrease the chances of scores overlapping.
Finally, one may wish to compare the present SRT to
memory measures which test a broader range of functions and

more clearly focus on such memory corelates of concentration

 

and attention. In any case the present study raises further

questions which should challenge future researchers.

 

APPENDICES

47

APPENDIX A

Beck Depression Inventory (BDI)

Date:
_

 

 

Name: Marital Status: __ Age: __ Sex:

Occupation: Education:

 

This questionnaire consists of 2 1 groups of statements. After reading each group of statements carefully.
circle the number (0. l. 2 or 3) next to the one statement in each group which best describes the way you
have been feeling the past week. including today. If several statements within a group seem to apply equally
well. circle each one. Be sure to read all the statements in each group before making your choice.

 

I 0 I do not feel sad. 8 0 I don't feel I am any worse than
I I feel sad. anybody else.
2 I am sad all the time and I can't snap out of it. i I am critical of myself for my weaknesses
or mistakes.

3 I am so sad or unhappy that I can't stand it. ,2 I blame myself all the time for my faults.

2 o I am not particularly discouraged about the a fiéfifpfl'gg If for eve : mg bad
future.
: I feel discouraged about the future. 9 U I don't have any thoughts of killing myself.
- I feel I have nothing to look forward to. l I have thoughts of killing myself but I
“J I feel that the future is hopeless and that would not. carry them our. '

things cannot 1mPI‘OVQ- 2 I would like to kill myself.

3 o I do not feel like a failure 3 I would kill myself if I had the chance.
1 I feel I have failed more than the .
average person. “I 0 I don t cry any more than usual.
2 As I look back on my life. all I can see is ' I 01'? more now than I used to.
a 10‘ of failures. 2 I cry all the time now.
l

3 I feel I am 3 complete failure 35 a person. I used to be able to cry. but now I can't cry

even though I want to.
4 0 I get as much satisfaction out. of things as I

USCd .tO- . . II 0 I am no more irritated now than I ever am.
I I don t enjoy things the way I used to. _ I I get annoyed or irritated more easily than
2 I don't get real satisfacan out of anything I used to.

anymore. _ 2 I feel irritated all the time now.
3 I am dissatisfied or bored with everything. 3

I don‘t get irritated at all by the things that
used to irritate me.

5 0 I don’t. feel particularly guilty.

 

 

 

 

‘ I feel guilty a 800d Pm Of the time. 12 0 I have not lost interest in other people.
2 I feel quite guilty 3105'- Of the time. i I am less interested in other people than
3 I feel guilty all of the time. I used to be.
2 I have lost most of my interest in
I 0 I don't feel I am being punished. Other people. ' ‘
, I feel I may be punished. 8 I have lost. all of my interest in other people.
2 Iexpecttobepunished. 13 I ak d . . b0 ll
. - ~ 0 m e eczsxons a ut as we as
J I feel I am being pumshed. I ever could.
. I t akin d ' '
7 o I don't feel disappointed in myself. I I 32ng g eczsxons more than
‘ I am disappointed in myself- 2 I have greater difficulty in making
2 I am disgusted with myself. decisions than before.
a I hate myself. ‘J I can't make decisions at. all anymore.
Subtotal Page 1 CONTINUED ON BACK

 

 

(A (THE PSYCHOLOGICAL coammnm
(‘13-, HA acounr BRACE [OVA NOVICH. m :.

Copyright I) 1978 by Aaron 1’. Seek. All rights reserved. PfInIeO m the U S A

NOTICE; It :3 against the law to photocopy or OIHEMISE reproduce
II'IIS questionnaire Without the publisher's written oerrmssmn 9.013359

48

 

 

 

 

 

 

1‘ U I don't feel I look any worse than I used to. 19 0 I haven't lost much weight. if any. lately.

‘ I am worried that I am looking old or 1 I have lost more than 5 pounds.

witrhactit‘: h 2 I have lost more than 10 pounds.

3 ea at ere are permanent c anges .

in my appe as that make me look J I have lost more than 15 pounds.
unattractive.

a I believe that I look ugly. I am purposely trying to lose weight by
eating less. Yes No

15 0 I can work about as well as before. 2" _ be

I It takes an extra effort to get started at o ihfifigsfim worried a ut my health

doing something. bo h bl

2 I have_to push myself very hard to do ‘ £32333m3w1§§1§$et ems

anything. stomach. or constipation.

3 I can t do any work at all. 2 I am very worried about physical
problems and it' 8 hard to think of
much else.

J I am so worried about my physical
‘8 o I can sleep as well as usual. problems that I cannot think about
1 I don't sleep as well as I used to. “mg else
'3 I wake up 1 -2 hours earlier than usual
and find it hard to get back to sleep.
3 I wake up several hours earlier than I 2‘ . d ch
used to and cannot get back to sleep. 0 .Ihavenot notice any recent ange
in my interest in sex.
t I am less interested in sex than I used
to be
17 ° I don’t get more tired than “SUB-L 1’ I am much less interested in sex now.

‘ I get W more easily than I used to. a I have lost interest in sex completely.

'2 I get tired from doing almost anything.

3 I am too tired to do anything.

18 U My appetite is no worse than usual.

I My appetite is not as good as it used to be.

2 My appetite is much worse now.

3 I have no appetite at all anymore.

Subtotal Page 2
Subtotal Page 1
__ 'Ibtal Score

 

 

 

 

TPC 0523.001 13 u 15 16 17 18 19 20

 

49

APPENDIX B

Senile Dementia of the Alzheimer's Type Battery

I.

Write response verbatim in the space provided.

LOGICAL

(S

MEMORY

points as trained.

DAT-battery)

SEEECTIWJEER
EflTE

Score half or whole

"I am going to read to you a little story of just a few lines
Listen carefully and try to remember it just the way I say it, as

close to the same words as you can remember.
want you to tell me everything I read to you.
all you can remember even if you are not sure.

READ STORY

A)

Anna Thompson/ of South/ Boston/
employed/ as a scrub woman/

in an office building/ reported/
at the City Hall/ Station/

that she had been held up/

on State Street/ the night before/
and robbed/ of fifteen dollars./
She had four/ little children/

the rent/ was due/
and they had not eaten/

for two days./ The officers/
touched by the woman’s story/
made up a purse/ for her./

Total

When I am through I
You should tell me
Are you ready?"

"Now what did I read to you? Tell me everything and begin at the

beginning."

RECORD

 

 

 

 

50

SENECTEWWBER
DATE

"Now I am going to read you another little story and see how much of
it you can remember. As with the first story, try to remember it
just the way I say it. Ready?"

READ STORY

B) The American/ liner/ New York/ +---+
struck a mine/ near Liverpool/ +—-—-—+
Monday evening./ +—--+
In spite of a blinding/ +---+
snowstorm/ and darkness/ +---+
the sixty/ passengers including eighteen/ +—————+
women/ were all rescued/ +---+
though the boats/ were tossed about/ +-——-+
like corks/ in the heavy sea./ +---+
They were brought into port/ +---+
the next day/ by a British steamer./ +—————+

Total +—————+

"Now what did I read to you? Tell me everything and begin at the
beginning.” RECORD

A

 

 

 

 

LOGICAL MEMORY:

A) Number of memories
B) Number of memories
Total

 

ota number of memor'es =
2

 

 

 

51

SUBJECT §ILT~E ER
DATE

MENTAL CONTROL: 7
1. "I want to see how well you can count backwards from 20 to 1
like this--20, 19, 18--all the way back to 1. Ready. Begin."

 

 

 

 

 

 

 

 

 

 

 

Time Errors
20 19 18 17 16 15 14 13 12 11 10 9 8 7 6 5 4 3 2 l
2. "I want to see how quickly you can say the alphabet for me--
A, B, C. . . Ready. Begin."

Time Errors
A B C D E F G H I J K L M N O P Q R S T U V w X Y Z
3. "I want to see how quickly you can count by 3’s beginning with
1. Like this--1, 4, 7. Ready. Begin."

Time Errors

 

1 4 7 10 13 16 19 22 25 28 31 34 37 4O

 

 

 

 

MENTAL CONTROL:

For tests (1) and (2) score 2 if no error within time limit of 30
seconds, score 1 if one error within 30 seconds, and score 1 credit
extra if subject repeats correctly with no errors within 10 seconds.
For test (3) score 2 if no errors within time limit of 45 seconds,
score 1 if one error within 45 seconds, and score 1 credit extra if
subject repeats correctly with no errors within 20 seconds. There
is a maximum of 3 points possible on each test.

 

Score Test 1
Score Test 2 Total Score
Score Test 3

 

 

 

TRAILMAKING:

"On this page (POINT) are some numbers. Begin at number 1 (POINT TO
NUMBER 1) and draw a line from 1 to 2 (POINT TO 2), 2 to 3 (POINT TO
3), 3 to 4 (POINT TO 4), and so on, in order, until you reach the
end (POINT TO THE CIRCLE MARKED END). Draw the lines as fast as you
can. Ready. Begin." TIME SUBJECT.

 

 

"Good. Let’s try the next one. Ready. Begin." TIME SUBJECT
TRAILMAKING: 1000 =

Number of seconds on drawing 2 seconds

Number of errors on drawing 2

 

 

 

Number of lifts on drawing 2

52

SENECTIWPEER
DATE

WORD FLUENCY:

"I'm going to say a letter of the alphabet and then I want you to
tell me all of the words you can think of that begin with that
letter. But proper names are not allowed, so if the letter were
"B" you would not say "Boston" or "Bob." The letter is "S."

Now tell me all the words you can think of that begin with the
letter "8." Ready. Begin." TIME FOR ONE MINUTE NOTING EACH

15 SECOND INTERVAL.

"Fine. We’re going to do the same thing again, but this time tell
me all the words you can think of that begin with the letter "P."

 

Ready. Begin." TIME FOR ONE MINUTE NOTING EACH 15 SECOND
INTERVAL.
Words beginning with "S" Words beginning with "P"

 

 

 

 

 

 

WORD FLUENCY:
Sum of "S" words Total number of words

Sum of "P" words

 

 

 

CANONICAL FUNCTION (REPORT TO 3RD SIGNIFICANT DIGIT):

 

+3.588
Logical Memory = {-u445 ) ( ) = -
Mentél Control = (4“130 ) 1 ) = +
Trailmaking = (-.066) ( ) = -
Word Fluency = (-.036) ( ) = '

 

 

TOTAL SCORE =

 

 

 

 

 

53

TRAIL MAKING

Subject #:

 

Interviewer:

 

Port A Date:

f

SAMPLE

 

m
‘3
CL

..
o

O

m
n
o
:3

 

 

 

 

 

55

APPENDIX C

Selective Reminding Task (SRT)

SENECTthBEQ
DATE

 

First Trial:

"I’m going to read a list of words to you. Listen carefully so you
can repeat them back to me. READ WORDS

Go ahead." RECORD WORDS

"Fine. Now I will tell you which words you forgot and when I’m
through I’ll have you tell me the entire list again.

You forgot. . . (READ WORDS THEY FORGOT) Now try to tell me the
entire list again. Go ahead."

All Subsequent Trials:

AFTER THEY HAVE SAID ALL THE WORDS THEY CAN REMEMBER

"Fine. Now I will tell you which words you forgot, and when I’m
through I’ll have you tell me the entire list again.

You forgot. . . (READ WORDS THEY FORGOT) Now try to tell me

the entire list again. Go ahead."

 

1 7 a .:

shine shine
disagree disagree
fat fat
wealthy wealthy

drunk drunk

pin pin

grass grass
moon ' moon
prepare ' prepare
prize prize
duck duck

leaf leaf

 

Intrusions: RECORD WORD SAID WITH RESPONSE NUMBER IN ().

 

 

 

 

 

l 7
2 8
3 9
4 10
5 11
b 12

 

 

56

SUBJECT NUMBER
DATE

 

 

Recall

 

LTS

 

LTR

 

CLTR

 

STR. >

 

Random ,

 

Reminders ,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SCORING
1. Hark all blank spaces on the scoring sheet with a large I.

2. Examine each word row (1-12). When two trials are recalled in a
row, underscore in red those trials and all subsequent trials in that row
(whether the word has been consistently recalled or not). This
represents long term storage.

3. Trace each word row backwards, from right to left, and place an
arrow in the numbered square following the last square with an I. There
should be no arrows in the 12th column (see sample). This represents
consistent long term storage.

u. Add the number of words recalled down each column and enter the
totals in the row marked RECALL.

5. Count down each column. the squares with numbers (recalled words)
that are underlined in red and enter total in the row marked LONG TERM
RETRIEVAL (LTR).

b. Subtract the LTR row From the RECALL row now by column and enter
the results in the row marked SHORT TERM RECALL (STR). Rhen the line
marked LTR and STR are added together. they will equal the line marked
RECALL.

7. Add cumulatively down the columns only those numbered blocks having
arrous, and enter the totals in the row marked CONSISTENT LONG TERM
RETRIEVAL (CLTR).

8. Count down each column. the squares (with an I or number)
underlined in red and enter the totals in the row marked LONG TERH
STORAGE (LTS).

9. Subtract the row marked CLTR from the (LTR) row by column and enter
the remainder in the row marked RANDON (RANDON LTR).

10. Sum across the LTR row and enter total at the end on the right.

11. Sum across the CLTR roe and enter total at the end on the right.

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57

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