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GROUP INTERVENTIONS FOR MEMORY COMPLAINTS, MEMORY IMPAIRMENT,
AND DEPRESSION IN THE ABLE ELDERLY

By

Barbara Jeanne Clark

A DISSERTATION

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

DOCTOR OF PHILOSOPHY

Department of Psychology

1994

ABSTRACT

(ROUP INTERVENTIONS FOR MEMORY COMPLAINTS, MEMORY
IMPAIRMENT, AND DEPRESSION IN THE ABLE ELDERLY

By

Barbara Jeanne Clark

The purpose of the study was to determine whether

interventions for the elderly designed to provide both
specific memory training techniques and treatment for
depressive symptomatology would have a positive effect on
objective measures of cognitive function and on subjective
evaluation of memory ability. In addition, the relationship
between memory impairment, depression, and memory complaints
was examined.

Community-dwelling older adults (N = 150) agreed to
participate in this study and were assigned randomly to one
of three twelve-week experimental treatment conditions.
These included a cognitive-behavioral workshop, a
meditation-relaxation workshop, and a waiting list that
served as a control. All volunteers were interviewed and
pre-tested with the Senile Dementia of the Alzheimer Type
battery, the Mini Mental State Examination, the Beck
Depression Inventory, and the Geriatric Depression Scale.
Each person also provided information about subjective
memory complaints. Participants were post-tested with the
same battery immediately following their completion of one
of the three treatment conditions.

Results indicate that, while the majority complained of

problems with their memory, most scored in the normal range
on both objective measures of cognitive function and
subjective measures of depression. All groups had decreased
memory complaints in post-testing and none of the
participants in the cognitive-behavioral group complained
about memory deterioration. Results indicate no
statistically significant relationship between depression
and memory loss or between depression and memory complaints.
Type of treatment used had no statistically significant
impact on memory complaints or on depressive symptomatology.
Data analysis did not reveal any significant improvement in
cognitive function with any treatment intervention. These
findings were discussed in terms of the difficulty in making
a clinically appropriate treatment intervention for
relatively high-functioning older adults who live

independently in the community.

ACKNOWLEDGMENTS

This dissertation would be incomplete without
acknowledging those who helped make it possible. First of
all, I would like to thank my advisor, Dr. Norman Abeles,
for his continued support throughout my years of study at
Michigan State University. Dr. Abeles has guided me in my
career and made it possible for me to take an active role in
research during my years at the Psychological Clinic. He
has also been very kind to my entire family. I respect Dr.
Abeles very much.

I would also like to thank Dr. Raymond Frankmann for
his patience and time. Dr. Frankmann was very helpful in
explaining statistical procedures and never talked over my
head or made me feel I should know everything about complex
analyses.

I would also like to thank my husband, Lee, and my
parents for always being there for me. It is not possible
to put into words all the love and support they have given

me over the years.

iv

LIST OF TABLES.

INTRODUCTION.

TABLE OF CONTENTS

REVIEW OF THE LITERATURE.

Memory loss in the elderly

Depression in the elderly.

Memory loss and depression
Memory complaints in the elderly

in the elderly. .

Treating the demented/depressed elderly. . .

Types of treatment for the elderly

Summary.

METHOD. . .

Participants/Procedures.
Instrumentation.

Senile Dementia of the Alzheimer Type

Mini Mental State Examination.

Geriatric Depression Scale

Beck Depression Inventory.

Statistical Analysis

HYPOTHESES.

RESULTS . .

Descriptive statistics
Depression and memory complaints
Treatment of depression and memory
Memory loss and depression
Treatment of memory complaints
Multiple regression.

DISCUSSION.

Depression and memory complaints
Treatment of depression and memory
Memory loss and depression
Treatment of memory complaints

Multiple regression.

Conclusion

Summary.
APPENDIX A.
APPENDIX B.

REFERENCES.

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LIST OF TABLES

Table Page
1. Comparison of participants receiving
cognitive-behavioral intervention with
those receiving meditation-relaxation
intervention on two variables--
depression and memory loss . . . . . . . . . . . . . 49

2. Comparison of participants receiving
cognitive-behavioral intervention with

those receiving no treatment (waiting
list) on two variables--depression

and memory loss. 0 O O O I O O I O 0 O O O O O O O O 50

3. Comparison of participants receiving
meditation-relaxation intervention
with those receiving no treatment
(waiting list) on two variables--
depression and memory loss . . . . . . . . . . . . . 50

vi

INTRODUCTION

The number of Americans over the age of 65 is growing
rapidly and will more than double by the year 2030. The very
old, those 85 and older, are the fastest growing sector of
our population. As a result of these changes, illnesses of
the elderly will necessarily increase dramatically. Two
disorders common among the elderly are dementia of the
Alzheimer type and depression, and understanding the nature
of these disorders and their treatment provides the
conceptual framework for this research.

Alzheimer’s disease was originally diagnosed in a 51
year old woman, and this case study in 1907 established a
variety of behavioral symptoms of the disorder (Perry,
Francis, & Clarkin, 1985). Alzheimer-type dementia is now
considered to be a brain disease occurring predominantly in
the elderly and is characterized by a progressive loss of
intellectual and functional abilities. The disease is
particularly associated with memory loss. In dementia there
are three major phases: an early phase of forgetfulness, when
the deficit is usually subjectively noted though verifiable
in cognitive memory testing, followed by an intermediate,
confusional phase, when cognitive deficits are readily
apparent to family and friends, and finally a late dementia
phase, indicated by the onset of impairment so severe that
independent existence is impossible (Gilleard, 1984).

Even normal aging is characterized by losses, such as

l

the loss of spouse and friends to death, the loss of physical
health, and other stresses associated with growing old. The
combined effect of these and other traumatic life events that
are common in old age often contribute to making an elderly
person feel powerless and depressed. Depressive
symptomatology includes depressed mood, feelings of
hopelessness, helplessness, and worthlessness, problems with
eating and sleeping, and psychomotor retardation. The
elderly who are depressed also experience loneliness,
withdrawl from any social support network, and a lack of
interest in pleasant activities.

Elderly persons who are depressed frequently complain of
memory impairment. For example, they complain that they are
unable to recall names and faces, forget appointments, are
unable to recall where they put things, and cannot think of
words and facts they want to use in conversation. Many
people have an unrealistically low expectation of their
abilities as they grow older. One of the factors that erodes
confidence and prevents the elderly from realizing their full
potential is the fear that something is happening to their
memory. The elderly do not realize that as they grow older
their thinking is slower, maintaining attention becomes more
difficult, more memory cues are needed, and learning takes
longer. In fact, symptoms of depression such as decreased
interest and decreased concentration make learning and
recalling information more difficult. Successful remembering

requires attention and concentration, motivation and effort,

and the application of memory strategies. If an elderly
person is depressed, they will not be able to pay attention
to something that they need to remember. Feelings of guilt
or worry about problems can dominate thinking and make it
impossible to recall events. Slowing down of thinking is
common in depression and makes it more difficult to apply
effective memory strategies.

Nevertheless, unlike Alzheimer-type dementia, cognitive
deficits related to depression are reversible in the majority
of otherwise healthy elderly persons. The chance of a
positive treatment outcome underscores the need for cost
effective mental health services that will contribute to
keeping the elderly in the community while at the same time
furthering our understanding of normal and pathological age-
associated memory functions. Treatment outcome becomes more
complicated, however, when an elderly individual suffers from
both memory impairment and depression.

The impact of depression on the cognitive functions of
elderly persons with serious memory impairment seems to be
substantial. Estimates of depression range from 66% to 87%
in Alzheimer-type dementia (Fischer, Simanyi, & Danielczyk,
1990; Rubin, Zorumski, & Burke, 1988). Rovner, Broadhead,
Spencer, Carson, and Folstein (1989) found that major
depression in Alzheimer patients was associated with greater
impairments in cognition and in capacity for self-care.
Depression is generally more likely to be present in the

elderly with mild to moderate levels of memory impairment.

Major depression in elderly patients is associated with
greater impairments in cognition and in capacity for self-
care. Finding greater cognitive impairment in depressed
elderly persons is not unexpected, as depression may worsen
already impaired cognition (Rovner, Broadhead, Spencer,
Carson, & Folstein, 1989). Given that depression in older
persons appears to interfere with cognitive functioning and
self-care activities to a greater degree than in younger
persons, identifying specific treatment approaches that will
alleviate depression is critical to reducing the elderly’s
dependence on an already strained health care system. It is
estimated that of those with organic mental disorder, 10% to
20% have remedial, or partially remedial dementias (LaRue,
Dessonville, & Jarvik, 1985). When depressive symptoms are
recognized, clinicians should consider the impact of these
symptoms on the elderly person’s ability to live
independently and must plan to treat potentially reversible
symptoms. Treatment plans may successfully address such
areas of concern as cognitive competence, psychological well-
being, and perceived quality of life.

It is clear that treatment planning for the elderly
population represents many challenges for health care
providers. In late life physical, social, and psychological
challenges to adaptive skills multiply. Since the elderly in
residential care settings have been given disproportionate
attention, relatively little treatment has been offered in

the community. Furthermore, the majority of demented elderly

persons live in the community. This underlines the as yet
unattended problems of the mildly or questionably demented
elderly population who are at high risk for concomitant
symptoms of depression that exacerbate memory impairment.

Most treatment approaches used with the elderly have
been borrowed from work with other client populations. Even
so, results from a number of treatment studies have provided
evidence that elderly individuals may present major cognitive
deficits that later remit spontaneously or improve following
treatment for depression (LaRue, Dessonville, & Jarvik,
1985). Successful treatment methods include traditional and
nontraditional forms of individual and/or group
psychotherapy as well as drug therapy.

Interventions such as giving aged individuals increased
control over and responsibility for important outcomes has
positive effects on their well-being and affective states
(Schulz, 1985). Other strategies that have been shown to be
effective in alleviating depression include training in
assertiveness, progressive relaxation, self-control, decision
making, problem solving, communication, time management, and
increasing pleasant activities. Memory strategies can be
aimed at circumventing a specific memory impairment by using
other intact skills to aid remembering. Successful
approaches to treatment can potentially link the cognitive
and behavioral approaches to depression by encouraging the
elderly to exercise more control, take responsibility for

actions and change, and develop more realistic

interpretations of events (Hanley & Baikie, 1984). Wilson
and Moffat (1984) identify two main reasons why memory
therapy groups might be considered for the elderly. First,
the elderly frequently complain that their ability to
remember and to retrieve information is not as good as it
used to be. For some individuals this might be a consequence
of reduced abilities, but for many others, depression, or the
expectation of memory loss with aging, may result in memory
complaints in the absence of impairment on memory tests.
Therefore, treating depressive symptomatology through a
variety of means including psychotherapy might help to reduce
depression and memory complaints. Second, a variety of
memory strategies have been successfully applied with the
elderly and might be incorporated into a memory therapy
group.

Accordingly, the focus of the present study is on
treating late-life memory impairment, depression, and memory
complaints in the elderly. The purpose of the study was to
determine whether workshops for the elderly designed to
provide both specific memory training techniques as well as
treatment for depressive symptomatology would have a positive
effect on objective measures of cognitive function and on
subjective evaluation of memory ability and depressive
symptomatology. In addition, the relationship between memory
impairment, memory complaints, and depression in the elderly

was examined.

REVIEW OF THE LITERATURE

Memory Loss in the Elderly

Dementia is one of the major health problems in the
elderly and appears to increase exponentially with age.
Prevalence rates vary greatly between surveys. Ciocon and
Potter (1988) report that 50% of individuals over 60 complain
of memory problems, with dementia the most common cause of
memory impairment in the elderly. The prevalence rate of
dementia has been estimated to be 5%-20% for individuals over
65 years of age, rising to 20% for those over 80, and a
prevalence rate for mild dementia of between 10 to 50%
(Larson et al., 1989; La Rue & Jarvik, 1987; Lazarus, Newton,
Cohler, Lesser, & Schweon, 1987; McCartney & Palmateer, 1985;
McIntyre & Frank, 1987; Mowry and Burvill, 1988; Small &
Jarvik, 1982).

The physical and psychological consequences of dementia
are devastating. Stern and Bernick (1987) state that
"dementia is a syndrome of diffuse disturbance of cognitive
functions in an alert patient of sufficient severity to
interfere with social or occupational performance; a defect
in memory is always present" (p. 44). Vitaliano, Breen,
Albert, Russo, and Prinz (1984) report that there is a
positive association between mental status scores, long-term
diagnosis, and the ability to live independently. Although
it is accepted that as individuals age there are declines in

intellectual processing and memory, it is hard to distinguish

age-associated declines from a dementing process (Morrow et
al., 1988; Stern & Bernick, 1987). Dementia of the Alzheimer
Type is described as the most common cause of dementia in the
elderly population (Bayer, Pathy, & Twining, 1987; Larson et
al., 1986).

Early dementia is a disorder that primarily affects the
elderly and is characterized by a wide range of symptoms such
as failing attention and memory, errors of judgment,
irritability, and poor orientation (Ashford, Kolm, Colliver,
Bekian, & Hsu, 1989; Haggerty et al., 1988; Meyer & Schuna,
1989; National Institute on Aging Task Force, 1980; Tuokko &
Crockett, 1989). The elderly individual with memory problems
forgets names, overlooks appointments, fails to recall the
day’s events, leaves tasks unfinished, and becomes ignorant
of the date, time of day, or season of the year (Roth, 1976).
Memory problems may be concealed by elderly persons who have
high initial intelligence, but as these problems magnify, the
individual is unable to recall past events as well.

Mild degrees of intellectual impairment are relatively
common in the older adult population, and these individuals
may be at risk for further dementing processes, or these may
be age-associated (late-life forgetting) memory impairments.
Whether normal aging, late-life forgetting, and mild dementia
lie on a continuum is uncertain. Rubin, Morris, Grant, and
Vendegna (1989) state that distinguishing normal aging from
very mild SDAT is difficult and that the addition of the term

age-associated memory impairment (late-life forgetting) makes

it even more difficult to positively identify mild SDAT.

The earliest change that is noted in the dementing
process is usually identified as a selective impairment of
memory for recent events. Ashford et al. (1989) found that
items on the Mini Mental State that were associated with
earliest loss were recent memory items. They reported that
items associated with a moderate level of dementia were time
and place orientation questions utilizing longer term memory
functions. Finally, severe dementia was characterized by
loss of early-learned verbal mimicking, the ability to name
simple objects, and the ability to follow simple commands.
Roth (1976) states that an elderly individual with dementia
is characterized as having progressive impairment of memory
and orientation for time and place, a decline in intellectual
grasp and comprehension, deterioration of the personality and
functional abilities, and mood lability. Petry, Cummings,
Hill, and Shapira (1988) state that personality alterations
are an integral part of the clinical presentation of
Alzheimer’s type dementia.

It is important to assess for dementia in the elderly
population even though symptoms of forgetfulness and
difficulties in understanding and coping with life stresses
are often attributed to simply becoming old (Bayer et al.,
1987). In fact, many physicians disregard such symptoms
because of preconceived notions of how an elderly patient
will present and fail to recognize a dementing process (Bayer

et al., 1987; Pace, 1989). Teri, Hughes, and Larson (1990)

10

state that knowledge about risk factors for a more rapid
progression may help with treatment planning. Therefore, it
is important to identify variables that might influence
decline such as coexistent emotional, social, and physical
conditions.
Depression in the Elderly

One such variable that is a major problem in the elderly
population is the presence of depression. The incidence of
depression increases as age increases, and, as with dementia,
the prevalence rates reported are highly variable (NIA Task
Force, 1980). The prevalence of depression in the elderly
population has been estimated to be between 10-15%, and the
prevalence of less severe depressive symptoms,
disproportionately greater in the elderly, has been estimated
to be between 5-44% (Alexopoulos, Young, Meyers, Abrams, &
Shamoian, 1988; Blazer, Hughers, & George, 1987; Good,
Vlachonikolis, Griffiths, & Griffiths, 1987; Griffiths, et
al., 1987; Harper, Kotik-Harper, & Kirby, 1990; Reifler,
Larson, & Hanley, 1982). Depression is estimated to affect
up to 12% of the general population of the United States at
any one time. Reifler, Larson, Teri, and Poulsen (1986)
reported that 24% of the elderly have significant depressive
symptoms. Indeed, depression is the most common
psychological complaint among the aged. Blazer et a1. (1987)
cite studies which found the prevalence rate of depression to
be present in 13%-21% of older adults over the age of 65.

Many of the elderly who are depressed are unlikely to be

11

diagnosed and treated. Freedman, Bucci, and Elkowitz (1982)
report that the highest rate of depressive symptoms is found
in those over 65 who live in the community. Henderson and
Kay (1984) cite a study of community-dwelling elderly that
found the prevalence rate of depression in individuals over
the age of 65 to be 8.1%. They also reviewed another study
that randomly selected persons over the age of 65 living in
the community and found prevalence rates of depression to be
13%.

Because of the increased likelihood of multiple
psychological, social, physical, and cognitive losses, the
elderly are at a greater risk for developing depression than
any other age group. Salzman and Shader (1979) point out
that in the context of declining function, limited coping
strategies, loss of interpersonal support, and stress such as
disease, it is not surprising that late-life depression
evolves. They go on to say that the loss of health,
cognitive abilities, coping strategies, employment, and
independence, work to lower an older adult’s self-esteem and
bring on a depressive episode. An elderly individual may
feel no longer valued and an encumbrance instead.

Many depressed elderly patients present the classical
major depression syndrome which includes depressed mood, poor
appetite, weight loss, insomnia or hypersomnia, motor
agitation or retardation, loss of energy, diminished
concentration, feelings of worthlessness, guilt, and suicidal

thoughts. However, many elderly individuals have symptoms of

12

depression that, while not severe enough to warrant a DSM-
III-R diagnosis, severely affect their ability to function
successfully in the community.

Dementia and depression are related, but the overlap
between the two represents a diagnostic challenge (Spar,
1982). Unfortunately, it is difficult in some instances to
determine whether an elderly individual is clearly
experiencing memory problems as a result of intellectual
impairment and decline in cognitive functioning. At times,
it may appear that an older adult suffers from dementia, when
in fact a depressive state appears as dementia (Thompson,
1986). This condition is referred to as pseudodementia, and
it is different from true dementia in that the underlying
depression of pseudodementia is treatable.

Some researchers consider depressive pseudodementia a
special subgroup of affective disorders in the elderly while
others reject the concept of pseudodementia on clinical and
psychopathological grounds (Salzman & Gutfreund, 1986).
Reifler (1982) states that the term pseudodementia is
overused and misused and should be retired from use in
clinical practice. He points out that pseudodementia implies
that organic deficits and mood disorders are mutually
exclusive processes instead of recognizing that both
depression and dementia can coexist in the same individual
and that cognitive impairment is affected by many variables.
In the most comprehensive paper on pseudodementia, Kiloh

(1961) wrote that the term was purely descriptive and carried

13

no diagnostic weight.

In research on pseudodementia, Reifler (1982) found that
in an elderly population, 55% were suffering from both
cognitive impairment and depression, while only 15% appeared
to have cognitive impairment due to depression. Roth (1976)
states that 15% of elderly persons who are depressed exhibit
cognitive impairment. Clinical research has shown that the
memory problems of older adults with pseudodementia improve
once the depression is effectively treated (Salzman & Shader,
1979). In a case of true dementia this would not happen.

Pseudodementia is described by Wells (1970) as the
syndrome in which dementia is mimicked by depression.
Although their performance on mental status examinations may
point to organic brain disease, this is usually not the case;
their affective states usually inhibit their performance
making it appear that they are demented. Researchers have
identified the presentation of an elderly person with
pseudodementia as follows: a) complaints and distress over
declining cognitive abilities, b) history of recent, abrupt
onset of symptoms that fluctuate over time, and c) appearance
of depression at examination (Benson, 1982; Black & Hughes,
1987; Caine, 1981; Feinberg & Goodman, 1984; Fopma-Loy, 1986;
Haggerty et al., 1988; Jorm, 1986; Reding, Haycox, & Blass,
1985; Small & Jarvik, 1982; Spar, 1982). Furthermore, Caine
(1981) has reported that persons with pseudodementia have
specific deficits in attention-concentration-arousal,

spontaneous verbal elaboration, and rapid, detailed analysis.

14

Memory Loss and Depression in the Elderly

Although it appears true that depression can be masked
by findings suggestive of dementia, depression and dementia
can also coexist in an elderly individual (Devanand & Nelson,
1985; Merriam, Aronson, Gaston, Wey, & Katz, 1988; Reding et
al., 1985; Stein & Bernick, 1987). Reifler et al. (1982)
state that the concept of pseudodementia did not seem helpful
in dealing with the mixed presentation of coexistent
dementing and depressive disorders. It has been observed
that depressed patients can develop cognitive impairment
including deficits in attention, memory, conceptualization,
and speed of mental processing (Alexopoulos, et al., 1988).
Alexopoulos and his colleagues state that 20% of demented
psychiatric outpatients have been reported to meet criteria
for major depression, and up to 50% of demented individuals
living in the community have various degrees of coexistent
depression. Furthermore, it has been suggested that
depression may occur concomitantly with dementia in 40-50% of
Alzheimer’s patients (Wragg & Jeste, 1989).

In research on the coexisting disorders, Griffiths et
al. (1987) found that increasing dementia is associated with
increasing depression and that depression and dementia were
mutually exclusive diagnoses. Reifler et al. (1982) found
depression more frequently in patients with less severe
cognitive impairment. Reding et al. (1985) suggested that a
relatively severe impairment of intellectual functioning

might suggest the presence of a coexistent dementing disorder

15

along with depression. Bucht, Adolfsson, and Winblad (1984)
confirmed that depression existed in mildly demented (SDAT)
patients. Davis and Robins (1989) found the presence of
concurrent psychiatric disorders in demented elderly
subjects, one of which was depression. Lazarus et al. (1987)
found that elderly patients diagnosed with dementia had a
significantly higher frequency of depressive symptoms and
suggested that there might be a high frequency of concomitant
depressive symptoms in elderly patients diagnosed with
dementia. Reifler et al. (1982) found that depression and
dementia were distinct disorders in the elderly in that
depression was not a universal feature of early dementia;
two-thirds of the mildly depressed elderly patients did not
meet the DSM-III-R criteria for depression, and one-third had
no recognizable symptoms of depression. Finally, Reifler et
al. (1986) found that 25% of demented elderly patients also
suffered from a depressive disorder.

In a study which used the Mini Mental State and the Beck
Depression Inventory, researchers sought to relate the
severity of depression and cognitive dysfunction when they
coexist in an inpatient population (Cavanaugh & Wettstein,
1983). They found no relationship between the severity of
depression and cognitive dysfunction among subjects younger
than 65, and in those older than 65, only an insignificant
trend was reported. Although the trend indicated that
elderly patients with moderate to severe depression tend to

have more cognitive dysfunction, the authors state that both

16

conditions should be evaluated independently, as it appears
the severity of depression is not directly related to
alterations in cognitive processes (Cavanaugh & Wettstein,
1983).

Breen, Larson, Reifler, Vitaliano, and Lawrence (1984)
designed a study that compared the intellectual and memory
abilities of community-dwelling elderly with dementia with
those of elderly patients with coexisting dementia and
depression. They reported that depression did not exacerbate
the short-term memory impairment associated with dementia.
Data also indicated that depression was not associated with
appreciable alterations in the patterns of memory performance
that characterize dementia. The authors did not speculate as
to the absence of statistically significant differences, but
pointed out that their small sample size could have affected
the results in terms of making it easier to obtain
statistical significance.

In a more recent study, Teri et al. (1990) found that
the rate of cognitive decline in elderly patients with
Alzheimer’s type dementia was variable and associated with
both behavioral and health factors. However, they report
that feelings of depression, as well as behavioral symptoms
associated with depression, did not appear to have a
significant effect on scores on the Mini Mental State.

Teasdale and Beaumont (1971), in a study of cognitive
deficits, found a significant correlation between depressed

mood and memory impairment on a word-learning test.

17

Depression has also been found to be associated with
significant impairment on a free-recall task (Henry,
Weingartner, & Murphy (1973). The authors hypothesized that
depression interfered with the transfer of information from
short-term to long-term storage.

Memory Complaintgiin the Elderly

Elderly people frequently express concern over failing
memory. Community surveys have indicated that 50% of persons
over 60 years of age report serious memory problems, while
the proportion is even higher in persons referred to a
geriatric screening program (Zarit, Cole, & Guider, 1981).
The most common complaint is that memory for recent events is
poor, but that events from the remote past are easily
recalled.

Memory complaints may reflect an elderly person’s
awareness of real decline, stereotyped expectations of
intellectual deterioration in the elderly, or both. Far too
often, age stereotypes of failing memory lead to a self-
fulfilling prophesy. Elderly people who experience
occasional absentmindedness often mistakenly attribute it to
an age-related decrement.

Furthermore, earlier onset of memory decline is
associated with greater mental distress in an elderly person.
Such memory impairment may occur more rapidly and is
therefore more easily recognized by elderly people. If there
is evidence of a loss of established skills, with only a

gradual reduction of overall mental competence, the

18

deficiency may be more striking and frustrating.

Thus, it is not surprising that depression is
significantly correlated with subjective memory complaints in
the elderly. Among the elderly, depressed people are more
likely to make negative self-evaluations about their memory.
As a whole, the number of complaints made about memory
correlates strongly and positively with scores on depression
rating scales (O’Connor, Pollitt, Roth, Brook, & Reiss,
1990). Some clinicians have gone so far as to emphasize
subjective memory complaints as a diagnostic indicator for
depression. If this is so, subjective memory complaints
should decrease as depression lifts.

Research on memory complaints and depression in the
elderly has become a focus of research in recent years.
Depressed elderly persons achieve significantly lower total
memory test scores than normal subjects. O’Connor et al.
(1990) examined seven memory test items in order to determine
how depressed elderly persons differed from normals. They
found that two items in particular that discriminated between
the two groups, namely recall of information from the distant
past, and recall of a name and address.

In the same study, elderly persons who were both demented
and depressed performed better on cognitive tests than
demented patients who were not depressed, despite the former
group’s more frequent complaints of forgetfulness (O’Connor
et al., 1990). More than half the sample of demented

participants admitted that their memories had deteriorated.

19

Although many moderately demented elderly persons admitted to
having difficulties, their replies lacked conviction and few
of them were distressed when their deficits were exposed. In
contrast, the depressives commonly complained spontaneously
of forgetfulness. O’Connor et a1. (1990) also point out that
it is likely that depressed elderly persons are more likely
to ask for help with their memory than those who are
demented.

Other research has shown that depressed patients may
complain more of cognitive losses than patients with dementia
(LaRue, Dessonville, & Jarvik, 1985). However, even though
depressives characteristically exaggerate their deficiencies
and portray themselves in the blackest possible light, their
cognitive impairment cannot be dismissed as just a figment of
their imaginations. Wells (1979), in his article on
pseudodementia, states that the patient with true dementia
often appears oblivious to memory defects that are quite
apparent to the examiner, while the opposite is true with
pseudodementia. An elderly person with cognitive impairment
that is not organic in origin may complain of memory loss
that will not be apparent to the examiner unless the person
is tested for memory loss. Wells discovered that most of his
patients with pseudodementia complained of memory loss for
recent and remote events. In addition, several patients
mentioned memory loss for specific periods of time and
specific events which is considered unusual in genuine

dementia.

20

In other research on memory complaints, Raskin and Rae
(1981) reported that cognitive complaints were markedly
higher among elderly depressed patients relative to elderly
normals. Fifty-two percent of the depressed and 13% of the
normals reported at least occasional problems with memory.

Raskin and Rae (1981) provided evidence that depressed
patients rated themselves high on forgetting and other
cognitive disturbance factors. However, when assessed, these
participants performed best on a direct test of cognitive
function. The authors discuss implications that memory
complaints in the elderly are associated with depression,
whereas poor performance on memory tests is associated with
the organic impairment seen in dementia.

Finally, Zarit et al. (1981) report on a study that
found subjective memory complaints were significantly
correlated with depression but not with poor memory
performance. Even among the organically impaired, all of
whom had marked memory loss, complaints were made only if the
person was also depressed.

Treating the Demented/Depressed Elderly

Whether instruction in memory enhancement procedures
and/or treating depressive symptomatology also affects
subjective evaluation of memory is not clear. Whatever
treatment factors are responsible, complaints of memory
impairment have been shown to resolve as depression lifts.
Techniques for treating cognitively impaired elderly who are

depressed have ranged from various forms of psychotherapy to

21

prescription drug therapy to Zen meditation. Because of the
prominence of memory loss as a symptom of Alzheimer-type
dementia, a common cause of memory impairment, clinical
interventions often seek to control the effects of that
impairment.

Patients with dementing disorders such as Alzheimer’s
disease frequently develop depression at some point during
the course of their disorder (Alexopoulos et al., 1988).
Improvement in cognitive functions often occurs after
alleviation of depressive symptomatology in elderly persons
with these organic disorders. Accordingly, researchers and
practitioners seek to develop treatment plans that enable the
normal and mildly demented elderly to adapt successfully and
to cope with factors that are associated with depression in
old age. Such information can then be incorporated into
education and social intervention strategies to help reduce
loneliness, enhance self-esteem, increase feelings of life
satisfaction, and extend cognitive functioning.

Alexopoulos et a1. (1988) state that memory impairment
appears to be reversible, once there is a clinically
significant improvement in mood. Alleviation of memory
deficits, for example, has been found to correlate directly
with clinical improvement in depression.

Types of Treatment for the Elderly

What then can be said about the effects of treating

depression in patients with cognitive impairment? Is there

improvement in affect, cognition, or both? The available

22

evidence suggests that depressive symptomatology can be
successfully treated, but that cognitive deficits may or may
not significantly improve. Improvement in cognitive
functioning would appear to depend on the type of treatment
used to treat the elderly depressed and/or demented
individual.

In general, physician treatment of depressed elderly
patients consists of general counseling and tricyclic
antidepressant drug therapy. Psychiatric referral is
infrequent and is not used for therapy but for a second
opinion regarding diagnosis (Richter, Barsky, & Hupp, 1983).
The mainstay of treatment for major depression are the
tricyclics, despite the high incidence of serious coexistent
medical diseases, some of which contraindicate the use of
antidepressants.

Several studies have examined the outcome of depressed
elderly persons who have memory impairment after treatment
with antidepressants. Plotkin, Mintz, & Jarvik (1985)
compared subjective memory complaints in elderly depressed
outpatients treated with tricyclic antidepressants or group
psychotherapy to evaluate the relationship between
improvement in depression and decrease in subjective memory
complaints and to determine if the change in memory
complaints of successfully treated patients differed
according to treatment group (psychotherapy versus drug
therapy). Results indicated that of the 29 patients for whom

baseline and endpoint data were available, 16 had fewer

23

memory complaints and 9 had more memory complaints at the
endpoint. Plotkin et al. concluded that results confirmed
subjective memory complaints decrease with successful
treatment of depression, and that alleviation of depressive
symptomatology, regardless of treatment technique, accounted
for the reduction in memory complaints.

Henry, Weingartner, and Murphy (1973) found evidence of
an impaired ability to shift information from short to long-
term memory storage in depressed persons. They treated these
individuals with tricyclic antidepressants and found that
drugs that clearly alleviated depression were not associated
with significantly improved learning.

Sternberg and Jarvik (1976) treated elderly depressed
patients with antidepressants to determine whether these
patients would show improvement in short and long-term memory
functions. Results indicated that depressed patients showed
marked impairment in short-term memory before treatment and
that the greater the improvement of the clinical state, the
greater the improvement in short-term memory. Long-term
memory did not appear to be influenced by mood improvement.

Greenwald et al. (1989) conducted a study to determine
whether somatic treatment of depression would improve memory
functions in elderly demented patients. They found that
patients suffering from both dementia and depression scored
significantly lower on the Mini Mental State than those who
were demented only or depressed only. Following treatment

with antidepressant medication, mean scores on the Mini

24

Mental State for the depression only and for the
dementia/depression patients improved. Cognitive
improvements were.not reported in the dementia only patients
following treatment.

Finally, Reifler (1986) reports on a study that found
significantly greater improvement in the depressive symptoms
of groups of elderly patients receiving antidepressant
medication. Cognitive status, however, did not improve.

Another common technique used to treat memory
loss/depression in the elderly is to employ direct training
programs which incorporate specific memory strategies. Zarit
et al. (1981) report that in one project they evaluated
whether concerns about a failing memory could be reduced
through the use of direct training strategies, a technique
that we also utilized in our study. Results of the Zarit et
al. study indicated that memory performance improved and
subjective complaints decreased, but that gains were also
shown in a control group receiving only assertion training.
Zarit et al. (1981) state that despite specific improvements
in memory performance in persons taught four memory training
strategies, it was not clear that training per se resulted in
lower subjective memory complaints. It was noted that
participation in a group may have been the catalyst as a
consequence of the social support participants received.

It was concluded that in order to reduce concerns about
failing memory, training on tasks may be less important than

changing expectation and helping the elderly view

25

forgetfulness in a balanced way.

Karlsson et al. (1989) conducted a study of Alzheimer-
type patients and demonstrated the beneficial effects of
specific cuing for mild to severely demented patients. They
concluded that in order to demonstrate memory enhancement it
is necessary to provide a substantial amount of environmental
support as a guidance for the process of remembering.

Zarit, Zarit, and Reever (1982) employed cognitive
training strategies in order to improve memory performance
among community-dwelling elderly people with senile dementia.
Participants were assigned to either a didactic training,
problem-solving, or wait list group. Classes met twice a
week for 1.5 hours for seven session. Results reflected only
small improvements in memory performance, and these gains
were short-lived. Depression was not assessed.

Reminiscence training, the systematic use of recall to
increase self-esteem and help older people integrate past and
present experience, has received some attention in the
treatment of elderly depressed and/or demented persons. In a
study investigating the effect of a structured reminiscent
intervention program on the cognitive functioning of the
elderly, Merriam (1980) found that females, but not males,
significantly improved in cognitive functioning.

Another study by the same author found that the tendency
to reminisce was unrelated to level of intellectual
competency and decline of intellectual abilities (Merriam,

1980). It has also been reported that nondepressed

26

individuals reminisce more than those who are depressed,
supporting the use of reminiscent intervention with the
elderly.

Another treatment technique that has been used with the
elderly is reality orientation. Reality orientation assists
the elderly person with maintaining orientation to their
environment by providing cues to such things as time, place,
and person. Only one study reviewed by Greene (1984) found
any changes in cognitive functioning following reality
orientation therapy. On the other hand, Garland (1985)
states that reality orientation programs appear to produce
modest improvements in mental functioning.

Little has been done to evaluate the effect of reality
orientation on elderly persons living in the community.

Yet one group conducted by Greene and colleagues in 1983
reported some modest improvements in cognitive functioning
(Greene, 1984). After reviewing 13 evaluative studies of
reality orientation, there appears to be little consistent
evidence that it results in any demonstrable cognitive or
behavioral change.

Still another method used to treat symptoms of
depression and/or dementia in the elderly is relaxation.
Relaxation can be taught as a skill to cope with undesirable
cognitive and physiologic responses to stress. Relaxation of
muscle fibers is said to be physiologically incompatible with
tension and thus relaxation is a logical treatment for the

tense or anxious person. Some therapists have actually

27

prescribed progressive relaxation techniques for patients who
respond excessively or inappropriately to stressful situation
(Garrison, 1978).

Another procedure that gained popularity in combating
tension and anxiety in the mid to late 1970’s is
transcendental meditation, the classic Hindu mantra method of
meditation adapted to Western consumers. The repetition of a
common special sound (mantra) is reported to produce a
relaxation response that can enable an individual to deal
with everyday life stress (Garrison, 1978).

Ingersoll and Silverman (1978) focused on helping
elderly persons cope with anxiety resulting from recent life
changes through progressive relaxation techniques. They also
introduced a variety of behavioral techniques to help persons
deal with memory loss, boredom, and depression. Results
indicated that the relaxation training was not successful
in decreasing the anxiety and somatic concerns of most
participants. They did find, however, that the self-esteem
of almost every participant increased, although this may have
a follow-up or halo effect.

Participation in individual and/or group psychotherapy
has been demonstrated to be an effective method to treat the
demented and/or depressed elderly. Painful awareness by
patients of their memory impairment may lead to a depressed
outlook, requiring intervention aimed at alleviating
depressive symptoms. Furthermore, depression in the elderly

is often the result of trying to cope with the death of

28

spouse or friends, loneliness, loss of job, financial loss,
and chronic disease. The depressive symptomatology is often
psychogenic in origin and can by successfully treated by
psychotherapy (Kral, 1983). Kral states that this depression
also is common in Alzheimer’s patients and will respond to
supportive psychotherapy.

Schmid (1990) argues effectively that the elderly are
good candidates for psychotherapy. In an article about
dementia and psychodynamic dimensions in treatment, he states
that health care providers fail to fully realize the
potential for psychodynamic intervention. Schmid stresses
that elderly persons have the capacity to change and
develop. He concludes that psychotherapy almost certainly
helps the mind stay active, thus enhancing the complexity and
capacity of brain circuitry and improving cognitive
functioning.

Treatment can also be approached from a cognitive-
behavioral framework. Usually this approach focuses on
instruction in affective, behavioral, and interpersonal
skills. The ultimate goal of this approach is to equip
clients with the skills to cope effectively with their
problems in living.

Cognitive-behavioral approaches have shown that problem-
solving skills may be developed in a group format. Gallagher
and Thompson (1981) write that an elderly person can be
taught to monitor mood and daily activities, to see the

connection between these, and to formulate self-change plans

29

to increase the extent of pleasurable activities (Gallagher &
Thompson, 1981). LaRue and colleagues cite a study reporting
decreased depression and memory complaint in a frail, 74
year-old man treated with behavioral and cognitive techniques
in a group and in marital therapy.

As evidence of the effectiveness of supportive-
expressive psychotherapy, Wheeler and Knight (1981) describe
a case in which an elderly man was preoccupied with his
memory loss, exacerbating his depression. He felt he was not
fit to socialize outside of his family relationships because
he was afraid he would hurt people’s feelings when he could
not remember their names, or what they had told him, or what
he himself had started to say. While some of his memory loss
might have been due to brain injury, the therapists believed
more of it was due to depression and decided to treat the
depression with supportive individual and group
psychotherapy. Upon the successful resolution of his
depressive symptoms, improvements in this memory were seen in
a matter of weeks.

A study by Simons, Garfield, and Murphy (1984) examined
memory complaints in the elderly patient before and after
treatment for depression. In that study, elderly depressed
individuals who responded to outpatient psychotherapy had
fewer memory complaints after treatment. A study of younger
adult depressed outpatients provided complementary data on
self-perception and treatment outcome. Patients were

randomly assigned to receive cognitive therapy or

30

pharmacotherapy, and successfully treated patients showed
nearly identical changes on mood and cognitive measures
regardless of the type of treatment.

Summary

The majority of elderly persons with dementia live in
the community, and it is clear that there is a paucity of
appropriate and affordable resources for the mildly or
questionably demented elderly population. Furthermore,
elderly persons with Alzheimer-type dementia often experience
concomitant depression during the course of their illness.
Untreated symptoms of depression in these individuals may
exacerbate already existing memory impairment. For the
elderly patient with dementia who is faced with repeated
failure at tasks that were once easily completed, depressive
withdrawl may be one way to cope. For others with dementia,
depression is a common reaction to traumatic life events,
medical problems, and lack of confidants. The community-
dwelling elderly who are not demented are also at high risk
for depression as a result of poor physical health, loss of
social support, and other severe life events.

Depression has been shown to correlate to an elderly
person’s score on memory assessment batteries. It follows,
then, that if depressive symptomatology improves
significantly, memory will also show clinically significant
improvement. Groups designed to improve memory by treating
symptoms of depression appear to be an appropriate

intervention for the community-dwelling elderly.

31

Furthermore, individuals who suffer from memory impairment
may benefit from interaction with others having similar
disabilities. Many such people believe they are losing their
mind, and this fear may be alleviated by observing that there
are others with similar difficulties. Accurate assessment of
an individuals’ memory abilities, followed by feedback about
strengths and weaknesses, can provide elderly persons with
information about skills they need to learn in memory therapy
workshops. Participants in the workshops designed to improve
memory by treating depression may also give advice to each
other and may be more likely to use aids or strategies if
their peers are also doing so.

Therefore, memory therapy groups appear to be a viable
option for the demented and depressed as well as the normal
and depressed elderly who may or may not complain of memory
impairment. These workshops allow health care professionals
to offer a less expensive treatment option to those who
complain of memory impairment and depression. A variety of
memory strategies and counseling techniques have been
successfully applied with the elderly and might be
incorporated into a memory therapy group.

Finally, it is clear that the elderly often complain of
poor memory. For some, this might be a consequence of
reduced abilities, but for many others, depression, or the
stereotype of memory loss with aging, may result in memory
complaints in the absence of impairment on memory tests. It

is possible that memory therapy groups may help to reduce

32

memory complaints in the elderly by making them aware of
their abilities and age-associated weaknesses without falling

prey to age stereotypes of failing memory that lead to a

self-fulfilling prophesy.

METHOD

Participants

Participants for the study were elderly adults at least
55 years of age who were recruited systematically from the
greater Lansing area. Volunteers were obtained by presenting
the project to elderly living in retirement homes or
participating in senior citizen groups. Volunteers from the
community-at-large were also obtained through a series of
newspaper ads placed in the Lansing State Journal.

Potential volunteers (N = 253) were informed that they
would be expected to participate in an initial assessment
procedure during which their mood, memory and other cognitive
functions would be tested. All volunteers were told that
they would receive free feedback concerning their
performance. All volunteers were then eligible to be part of
a Coping with Aging workshop.

Elderly persons who decided to participate in the
project set up an appointment with a clinician who was
trained to administer a battery of assessment instruments
using a standard procedure. Clinicians assessed volunteers,
scored all measures, and turned in packets to a coordinator
who assigned numbers to each packet in order to protect
confidentiality. All investigators, graduate students in
clinical psychology, were trained in a standardized manner so
that all could administer assessment batteries and conduct

treatment workshops. All investigators had previous

33

34

experience with the elderly population and were supervised by
a fully licensed clinical psychologist who had expertise in
managing project involving this population.

The assessment battery administered during the initial
testing procedure included the Senile Dementia of the
Alzheimer Type (SDAT) battery, the Mini Mental State
Examination (MMSE), the Geriatric Depression Scale (GDS), the
Beck Depression Inventory (BDI). Also included were a
subject information sheet that collected demographic
and memory complaint information and a research consent form.

All elderly participants were assigned to Coping with
Aging groups on a random basis. For purposes of control,
each person was assigned to a treatment condition (workshop
or waiting list) regardless of whether they chose to
participate in a workshop and/or complete the battery of
assessment instruments. These workshops consisted of eight
one hour and fifteen minute sessions that met weekly, with
the last session devoted entirely to retesting. Two types of
groups were offered, one based on cognitive-behavioral
techniques and one based on relaxation-meditation techniques.
Both workshops had standardized protocols and were led by
trained graduate-student clinicians. The workshops were
designed to provide memory-training techniques as well as
treatment for depressive symptomatology effective in
improving memory and in lessening memory complaints. Group
leaders were not told how any participant had scored on the

memory and mood measures and always led workshops consisting

35

of participants of whom they had no prior knowledge.

The cognitive-behavioral workshop was based on a manual
titled Paychoeducational Intervention For Unipolar Depression
(Lewinsohn, Antonuccio, Steinmetz, & Teri, 1984). Also
incorporated into the cognitive-behavioral workshop were
aspects from the Depression in the Elderly: A Behavioral
Treatment Manual (Gallagher & Thompson, 1981) and The Coping
with Depresaion Course (Lewinsohn, Antonuccio, Breckenridge,
& Teri, 1984). Furthermore, specific memory strategies and
skills taken from Mamory FitnesaaOver 40 (West, 1985) were
discussed.

The relaxation-meditation workshOp was based on a method
of relaxation developed by Dr. Edmund Jacobson. In addition,
a brief meditation component consisting of the approach
described in The Relaxation Reaponaa (Benson, Beary, & Carol,
1974) was incorporated into the workshop.

Volunteers who made up the experimental control group
were told that a Coping with Aging workshop would be starting
in the near future and that they would be contacted as soon
as the workshop was going to begin. This group was pre-
tested at the same time as those who received group treatment
immediately. In addition, these individuals were post-tested
before starting one of the workshops and therefore served as
the control group for the cognitive/behavioral and
meditation/relaxation groups. Workshops were offered to the
control group that had been placed on a waiting list in order

to fulfill ethical obligations to provide the services

36

promised.

Post-testing of the elderly workshop participants
occurred after they had completed either the behavioral or
relaxation course. Each member was tested by a clinician who
administered a battery including the SDAT battery, MMSE,
WAIS-R vocabulary, SRT (6 trials), BDI, GDS, BSI, BDI, and
selected items from the MAI. Demographic information and
informed consent were obtained a second time. Clinicians
scored and turned in packets to the coordinator who matched
this data with data from the initial testing sessions.
Clinicians were not assigned to reassess a participant of
whom they had prior knowledge, either through pre-testing or
through workshop participation.

For the experimental control group who did not
participate in any workshop, post-testing took place
approximately two months after initial testing. The post-
test battery was identical to that used for workshop
participants. Clinicians scored and turned in packets to the
coordinator who matched this data with data from the initial
testing sessions.

Instrumentation

The assessment tools selected for use in the present
study were the following: (a) the Senile Dementia of the
Alzheimer Type (SDAT) test battery served as an objective
measure of cognitive function, (b) the Mini Mental State
Examination (MMSE) served as an objective measure of

cognitive function, (c) the Geriatric Depression Scale (GDS)

37

served as an objective measure of depression, (d) the Beck
Depression Inventory (BDI) served as an objective measure of
depression, and (e) selected questions from a subject
information/demographic sheet including age, highest grade
completed, and whether the subject complained subjectively of
memory impairment.
Senile Demantiappf the Alzheimer Type battery

The SDAT battery consists of tests of logical memory,
trailmaking, word fluency, and mental control (Storandt,
Botwinick, Danziger, Gerg, & Hughes, 1984). Storandt et al.
(1984) defined this battery of tests in order to
differentiate older individuals with mild SDAT from normal
older adults. Logical memory is assessed by asking the
participant to recall a prose passage after it is read to
them. Trailmaking A is a neuropsychological test involving
tracing lines from one circled number to another in
consecutive order. Word fluency is assessed by counting how
many words a participant could think of that began with the
letter S and P in a 60 second time limit. Mental control is
assessed by determining how quickly and accurately the
participants can recite the alphabet, count backwards from 20
to 1, and count by threes (1, 4, 7, etc). Following the
equation given by Storandt et al. (1984), a participant’s raw
score on the test is multiplied by the corresponding
unstandardized coefficient and then summed with the constant
to produce the canonical score. Those with canonical scores

equal or greater than 0 are classified as having dementia,

38

and those scoring less than 0 were classified as normal.
Major analysis involved a stepwise discriminant function
analysis designed to determine which measures and their
weights would discriminate maximally between subjects with
mild SDAT and normal controls. The first discriminate
analysis conducted with 42 subjects correctly classified all

subjects on the basis of a discriminate function using the

four measures mentioned above. Applying weights obtained
from this analysis to the cross-validation sample (n = 42),
all but 2 persons were classified correctly (98%). The two

samples were then combined to obtain more stable
coefficients.
Mini Mental State Examination

The Mini Mental State (MMSE) is a mental status
examination developed to provide a practical method for
grading the cognitive state of patients using a brief test
designed to assist clinicians in recognizing cognitive
impairment (Folstein & McHugh, 1975). The MMSE is divided
into two sections; the first covers orientation, memory, and
attention, and the second covers the ability to name, follow
written and verbal commands, write a sentence spontaneously,
and copy a simple design. Folstein et al. (1975) used 206
patients with dementia syndromes, affective disorder with or
without cognitive impairment, mania, schizophrenia, and
personality disorder, as well as 63 normal subjects to test
the reliability and validity of the MMSE. In validating the

MMSE, it was determined that the MMSE scores agreed with the

39

clinical opinion of the presence of cognitive difficulty and
as the cognitive difficulty is usually less is depression
than in dementia the scores dispersed in a fashion agreeing
the severity of the illness. Scores were not due to age
effects and unrelated clinical conditions (M = 24.5 for
patients with depression under 60 years; M = 25.7 for
patients with depression over 60 years). Change over time in
the MMSE score matched the actual improvement or decline in
cognitive state. Folstein et al. determined that the MMSE
is reliable on a 24 hour or 28 day retest by single or
multiple examiners (Pearson p = .887 when given 24 hours
apart; p = .98 when given 28 days apart).

The maximum score on the 5-10 minute test is 30.
Bleecker, Bolla-Wilson, Kawas, and Agnew (1988) established
age-specific norms for the MMSE, and the lowest quartile
cutoff scores by decade are as follows: 603 = 28; 705 = 28;
and 803 = 26. Using these age-specific norms provides
greater sensitivity than the recommended cutoff score of less
than 24.

Fischer, Simanyi, & Danielczyk (1990) established
cutoffs for the MMSE that identify elderly persons who are
mildly, moderately, and severely demented. These cutoffs are
as follows: (a) mildly demented = 16-23, (b) moderately
demented = 6-15, and (c) severely demented = less than 6.
Geriatric Depreaaion Scamp

The Geriatric Depression Scale (GDS) was specifically

designed to measure depression in the elderly and was

40

validated on 100 community-dwelling elderly and elderly
outpatients and inpatients over 55 years of age (Yesavage,
et al., 1983). This self-report scale was designed to be
used as a simple screening instrument and consists of 30
items that can be answered using a yes—no format. Of the 30
questions, 20 indicate the presence of depression when
answered positively, while 10 indicate depression when
answered negatively. The norms for the GDS are as follows:
normal = 5.75; mildly depressed = 15.05; and severely
depressed = 22.85.

For the GDS, tests of reliability and validity were
conducted by Yesavage et al. (1983) using two groups of
elderly subjects, normal (n = 40) and depressed (n = 60).
For reliability, the median correlation between items of the
GDS and the corrected-item total score was .56. The alpha
coefficient for internal consistency was .94, suggesting a
high degree of internal consistency. The split-half
reliability was .94, and the test reliability was .85. The
primary test of validity was provided by classifying subjects
as normal, mildly depressed, or severely depressed on the
basis of RDC criteria and then determining how well the GDS
score predicted the RDC diagnosis. The correlation between
the classification variables and the GDS score was .82, and
the main effect for the classification variable was
significant: E(2,97) = 99.48, p = .001.

Beck Depreaaion Inventory

The Beck Depression Inventory (BDI) consists of 21 self-

41

report symptoms and attitudes which are rated from 0 to 3 in
terms of intensity by the participant (Beck, Steer, & Garbin,
1988). The cut-off scores established to distinguish those
who have affective disorder from those who do not are as
follows: (a) less than 10 is considered minimal depression,
(b) 10-18 is considered mild to moderate depression, and (c)
30-63 is considered to be severe depression (Beck et al.,
1988). The mean BDI scores are as follows: (a) minimal =
10.9, (b) mild = 18.7, and (c) severe = 30.0 (Beck et al.,
1988). Beck et al. (1988) report that for psychiatric
populations, the mean coefficient alpha from 25 previous
studies for internal consistency was .86. For 15
nonpsychiatric studies, the mean alpha for internal
consistency was .81. Split-half reliability has been shown
to be .93, and test-retest reliability is .74 for 3 months.
The BDI correlates well with other symptom inventories and
can discriminate between diagnostic groups. For a detailed
discussion on the excellent content, concurrent,
discriminant, construct, and factorial validity of the BDI,
Beck et al. (1988) have reviewed the psychometric properties
of the inventory.

Selected questions from a participant information sheet
were included in the final analysis. These included the
following: (a) Are you currently experiencing any problems
with your memory?, (b) If yes, please tell us what kinds of
problems you are experiencing--remembering names? faces?

date, month, or year? appointments? where you put things?

42

what you went into a room to get? remembering to take
medication? other?, (c) Are you currently experiencing any
major problems with your memory, and (d) Are there any times
you don’t know the date, time of day, or the season of the
year? The answers to these questions were coded to reflect
participants’ memory complaints. The age, gender, and
highest grade completed were recorded for use in data
analyses.

Statistical Analysis

The following independent variables were considered in
analyzing the data: (a) age, (b) gender, (c) highest grade
completed, (d) one of three experimental treatment conditions
(cognitive/behavioral, meditation/relaxation, or waiting
list). The following dependent variables were considered in
analyzing the data: (a) depression, (b) memory loss, and (c)
memory complaints.

Initially, analyses were conducted to determine
frequencies for all independent and dependent variables in
order to provide descriptive statistics. Other statistical
analyses that were appropriate for the research problem as
determine by their possible contribution to results were
conducted as follows.

Pearson Product Moment Correlation analysis was used to
determine whether there were statistically significant
relationships between proportions of the variables. This
analysis examined the relationship between the preceding

variables and the direction of that relationship.

43

Chi Square analysis was used to determine whether there
were statistically significant differences between
categorical variables including pre versus post memory
complaints, controlling for each of three experimental
treatment conditions and also whether there were
statistically significant differences between each
experimental treatment condition versus post memory
complaint, controlling for pre-memory complaints. The
four-fold table was formed using the pre and post yes or no
answers in order to determine cell frequencies.

Selective two-tailed t-tests were used to analyze
whether there were statistically significant differences
between group means as calculated from the type of
experimental treatment and treatment outcome. Treatment
outcome was evaluated in terms of pre-post scores on the SDAT
and MMSE (measures of cognitive function), the EDI and GDS
(measures of depression), and pre-post memory complaints.
Additional t-tests were used to determine whether there were
any differences between the two active treatment modes while
controlling for memory impairment, memory complaints, and
depression.

Finally, multiple and stepwise regression was used to
determine the following: (a) the tendency of the variables to
covary, (b) whether treatment outcome (as measured in terms
of SDAT score) was associated with each independent variable,
(c) whether an independent variable is a surrogate for

another independent variable in the relationship with

44

treatment outcome, and (d) whether an independent variable
enhanced the effect of another independent variable or
treatment outcome. Multiple regression was used in order to
study the level of cognitive function, depression, and memory
complaints as a function of age, gender, highest grade
completed, and type of experimental treatment. Employing
such a strategy yielded results indicating whether these
independent variables correlated with each other as well as
with treatment outcome (memory impairment, depression, and

memory complaints).

HYPOTHESES

The present study was designed to test the following
hypotheses:
(1) Elderly individuals who are depressed will complain more
of memory impairment than those who are not depressed.
As scores on depression inventories increase (higher score =
more depressive symptoms), so will the number of memory
complaints.
(2) Elderly individuals who are depressed and are treated
with cognitive-behavioral or with meditation/relaxation
techniques designed to alleviate depression will score
lower (less depressed) on depression inventories after
treatment than will those who do not participate in any
treatment group.
(3) Elderly individuals who are depressed will have
more memory impairment than will those who are not depressed.
(4) Elderly individuals who are successfully treated for
depression will experience significant improvement on tests
of cognitive functioning. Cognitive-behavioral and/or
meditation/relaxation techniques designed to treat depression
will result in a remission of memory impairment as measured
by improvement in score on the Senile Dementia of the
Alzheimer-type battery and on the Mini Mental State
Examination. This effect will be seen in depressed only and
mildly demented/depressed individuals. Individuals who are

moderately to severely demented/depressed will not experience

45

46

a significant improvement on tests of cognitive functioning.
Individuals who receive no treatment will show no improvement
in cognitive functioning.
(5) Depressed-only as well as mildly demented and depressed
elderly individuals who complained of memory impairment
before treatment for depression will experience a significant
drop in number of memory complaints after treatment with
cognitive-behavioral or meditation/relaxation techniques.
However, the number of memory complaints of elderly
individuals who are moderately to severely demented and
depressed will stay the same.
(6) Memory loss, depression, memory complaints, and type of
treatment will fit a regression model. The model will
predict improvement in cognitive functioning and will show
that the variables mentioned correlate with improvement in
overall level of cognitive function.

Finally, additional tests will be performed in order to
determine whether there are any differences between the two

active treatment modes.

RESULTS

The 150 participants who completed all phases of this
study ranged in age from 55 to 92 years and included 117
females and 33 males. The average age of participants was 71
years. There was no loss of data due to mortality. The
educational grades completed by participants ranged from
grade 7 to grade 21 (post-grad); the average grade
participants completed was 13 years (one year of college or
vocational/trade school). Forty-two percent had 12 years or
less of education, but of this group, 31% had a high school
diploma. Thirteen percent had graduated from college, and 7%
had at least twenty years of education. Forty-four
individuals participated in the cognitive group, 48 in the
meditation group, and 56 volunteers served as controls.
Qaacriptive Statistics

In pre-testing, 70% of participants complained
subjectively about their memory, while 65% complained of
problems with memory in post-testing. However, on tests of
cognitive function, the majority scored in the normal range
on both pre and post-tests. The mean score on the Mini
Mental State for pre and post testing was 28 and 29
respectively, which is indicative of normal cognitive
functioning. On the Senile Dementia of the Alzheimer Type
(SDAT) battery, the mean scores for pre and post-tests were
-0.976 and -1.425 respectively, which is indicative of normal

cognitive functioning. Scores less than 0 are considered

47

48

normal, and scores greater than 0 are indicative of memory
impairment. Thirty percent scored in the demented range on
pre-tests and 21% scored in the demented range on post-tests.

On the questionnaires that assessed level of depression,
the majority scored in the normal range on both pre and post—
tests. One the Beck Depression Inventory pre-test, 70%
scored in the not depressed to minimally depressed range, 21%
in the mildly depressed range, and only 9% (10 individuals)
in the moderately to severely depressed range. On the Beck
Depression Inventory post-test, 73% scored in the not
depressed to minimally depressed range, 23% in the mildly
depressed range, and only 4% (5 individuals) in the
moderately depressed range. On the Geriatric Depression
Scale pre-test, 48% scored in the not depressed to minimally
depressed range, 44% in the mildly depressed range, and 8%
(11 individuals) in the moderately depressed range. On the
Geriatric Depression Scale post-test, 54% scored in the not
depressed to minimally depressed range, 37% in the mildly
depressed range, and 8% (12 people) in the moderately
depressed range. It should be noted that not everyone filled
out both depression inventories. Intercorrelations between
measures are presented in Appendix A.
Depreaaion and Memory Complaints

Hypothesis one predicted a significant positive
relationship between depression and memory complaints.
Pearson Product Moment correlational analysis determined that

there was not a statistically significant correlation between

 

49

memory complaints and depression (3 = .11).
Treatment of Depreaaion and Memory Loaa

Hypothesis two predicted a significant difference
between the type of treatment used and alleviation of
depressive symptomatology. Furthermore, it was hypothesized
that there might be a difference in how effective each active
experimental intervention was on levels of depression.

Hypothesis three predicted a significant difference
between type of treatment used and alleviation of memory
impairment. Furthermore, it was hypothesized that there
might be a difference in how effective each active
experimental intervention was on levels of cognitive
function.

In order to test these two hypotheses, t-tests were
conducted on type of treatment used and the following
variables--depression and memory loss. Results are indicated
in Tables 1, 2, and 3.

Table 1
Comparison of participants receiving cognitive/behavioral

intervention with those receiving meditation/relaxation
intervention on two variables--depression and memory loss.

 

 

N Mean §D L B
SDAT Score
cognitive group 44 -.66 1.32 -.57 .570
meditation group 48 -.51 1.24
MMSE Score
cognitive group 44 .23 2.24 -.21 .833
meditation group 48 .31 1.53
BDI Score
cognitive group 44 -.81 4.00 .98 .328
meditation group 48 -1.75 5.10
GDS Score
cognitive group 44 .17 .38 -.73 .465

meditation group 48 .23 .43

 

50

Table 2

Comparison of participants receiving cognitive/behavioral
intervention with those receiving no treatment (waiting list)
on two variables, depression and memory loss.

 

 

 

N Mean SD L 2
SDAT Score
cognitive group 44 -.66 1.32 -1.67 .098
control group 56 -.21 1.38
MMSE Score
cognitive group 44 .23 2.24 .18 .854
control group 56 .14 2.31
BDI Score
cognitive group 43 -.81 4.00 -.09 .925
control group 55 -.72 5.16
GDS Score
cognitive group 41 .17 .38 .62 .540
control group 56 .13 .33
Table 3

Comparison of participants receiving meditation/relaxation
intervention with those receiving no treatment (waiting list)
on two variables, depression and memory loss.

 

 

N Mean SD L p
SDAT Score
meditation group 48 -.51 1.24 -1.17 .245
control group 56 -.21 1.38
MMSE Score
meditation group 48 .31 1.53 .45 .656
control group 56 .14 2.31
BDI Score
meditation group 48 -1.75 5.08 -1.01 .314
control group 55 -.73 5.16
GDS Score
meditation group 47 .23 .43 1.42 .159
control group 56 .13 .33

 

There were not statistically significant results between
the independent variables, type of treatment, and any
treatment outcome (depression and/or memory loss). However,

two results approached significance. First, in comparing

51

post-test scores on the Senile Dementia of the Alzheimer Type

battery, the cognitive/behavioral workshop appears somewhat

more effective than not treating at all (t(94) = -1.67, p =
.098). Second, in comparing post-test scores on the

Geriatric Depression Scale, the meditation/relaxation
workshop appears somewhat more effective than not treating
at all (t(86) = 1.42, p = .16). There was not a
statistically significant difference when comparing the
efficacy of cognitive/behavioral versus meditation/relaxation
group treatment on depression and memory loss, and the only
two results that approached significance when comparing
either intervention against the control group are reported
above.
Memory Loss and Depreaaion

Hypothesis four predicted a significant positive
relationship between depression and memory loss. Pearson
Product Moment correlational analysis determined that there
was not a statistically significant correlation between level
of depression and level of cognitive functioning in this
population (p = .04).
Treatment of Memory Complaints

Hypothesis five predicted a significant relationship
between type of treatment used and number of memory
complaints after treatment. It was hypothesized that
participating in either cognitive-behavioral or meditation-
relaxation workshops would be significantly more effective in

reducing the number of memory complaints than receiving no

52

treatment. Furthermore, it was hypothesized that there might
be a difference in how effective each active experimental
intervention was on the number of memory complaints.

Chi Square analysis indicated that there was a
statistically significant relationship between pre-post
memory complaints and receiving cognitive/behavioral group
intervention (Chi Square (1) = 21.7, p = .0001). Fifteen
percent of participants who received this treatment did
complain less about their memory following treatment. Not
one participant agreed that their memory had deteriorated
from pre to post-testing, although 56% agreed that they still
believed they had memory impairment even after treatment.

Statistical significance was also achieved when
examining pre-post memory complaints and receiving treatment
based on meditation/relaxation techniques (Chi Square (1) =
8.35, p = .004). Twenty percent believed their memory had
improved, while 53% still believed they had memory problems.
However, three individuals (7%) in this group complained that
their memory had deteriorated following treatment. It is
also significant that those participants receiving no
treatment also showed an improvement in subjective memory
complaints (7%), and this finding was statistically
significant (Chi Sqmare (1) = 18.46, p = .00002). Sixty six
percent of this group did complain that they had memory
impairment at the time of pre and post-testing. Four
individuals (7%) agreed that they had less memory complaints

while 5 individuals (9%) indicated that they had more memory

 

53

complaints at the time of post—testing.

When Chi Square analysis was conducted on these
variables, controlling for pre-test memory complaints, the
following results were found. Of the individuals who did not
complain of problems, with memory initially, none of those
treated using cognitive/behavioral techniques believed their
memory had deteriorated over time, while three individuals
(5%) treated using meditation/relaxation techniques who
initially did not complain about their memory and five
individuals (13%) who were on the waiting list who initially
did not complain about their memory believed that their
memory had deteriorated between pre and post-testing.
Although this result approached significance, it was not
statistically significant (Chi SquapeAJZ) = 4.76, p = .09).
Of the individuals who initially complained of memory
problems, 6 of those treated using cognitive/behavioral
techniques, 9 of those receiving meditation/relaxation
techniques, and 4 of those who served as controls believed
that their memory had improved. These results did not
approach statistical significance.

Other Variables of Intereap

Post hoc analysis with Pearson Product Moment
correlational analysis examined the relationships between
other variables of interest. Results indicate that there was
not a statistically significant correlation between memory
complaints and level of education or memory loss (p = -.08,

p = .05). In addition, post hoc analysis with Pearson

 

54

Product Moment correlational analysis indicated that there
was not a statistically significant correlation between age
of participants and memory complaints, memory loss, or
depression (p = .06, p = .05, p = .05).

Post hoc analysis did indicate that there was a
statistically significant correlation between level of
education and level of depression. As level of education
increased, level of depression decreased from pre to post- :-
testing, regardless of the type of experimental treatment
condition (3 = -.21, p = .01).

Multiple Regression

Hypothesis six predicted that the variables in this
study would account for a significant pr0portion of the
variance and that four variables, memory loss, depression,
memory complaints, and type of treatment, would fit a
regression model. An analysis of variance was conducted
using stepwise and multiple regression. In looking at the
relationship between sets of variables, it was hoped that we
could learn both the absolute value as a predictor of the
entire set of predictors and the relative value as a
predictor of each independent variable compared to the
others. However, none of the variables fit into a step-wise
regression model as predictor variables. Likewise, analysis
using multiple regression did not turn up statistically

significant results. When trying to predict treatment

outcome, the type of treatment, level of depression, level of

 

memory loss, age, and level of education did not correlate

with the dependent variable.
Post Hoc Analyses
After examining preliminary results, it was hypothesized
that, in this relatively "healthy" sample of able elderly,
the results of interventions might be masked given the small
numbers of actually depressed and/or actually memory—impaired
individuals. Therefore, post-hoc analyses looked exclusively
at those individuals who met criteria for mild to severe f

depression, who met criteria for memory impairment, and

fr]
19

who met criteria for both. Results of t-tests indicate that
no active treatment intervention significantly helped those
individuals who met the above criteria. In determining the
difference in effectiveness of active treatment on those who
were initially depressed, results show neither had a
statistically significant impact on cognitive function (ayaml
= -1.17, p = .256) or depression (LL24) = .44, p = .663). In
determining the difference in effectiveness of active
treatment on those who were initially memory-impaired,

results show neither had a statistically significant impact

on cognitive function (t(3) = -.70, p = .526) or depression
(t(12) = .90, p = .386). Finally, we were unable to

determine the difference in effectiveness of active treatment
on those who were both memory-impaired and depressed since no
individuals who met this criteria participated in a cognitive
workshop. However, results indicated that, for this group,
receiving meditation-relaxation treatment proved no better

than control on tests of cognitive function (t(7) = .18, p =

DISCUSSION

The elderly population in the United States is growing
rapidly, and as a result, it has become increasingly
important for mental health care professionals to develop
clinically-appropriate treatment interventions for those
older adults who suffer from two common disorders of the
elderly, namely dementia and depression. Although
researchers have worked to develop instruments that will
accurately diagnose memory impairment and depression in the
elderly population, research on treating these conditions
has lagged behind.

In the past, health care professionals who attempted to
treat older adults with psychotherapy did so by applying
treatment techniques designed for and tested on a much
younger population without knowledge of the efficacy of
these interventions in the elderly. As late as 1992,
Abraham, Neundorfer, and Currie (1992) reported that no
controlled studies of interventions for depression in the
institutionalized elderly had been conducted. They also
pointed out in their review that the secondary effects of
psychotherapy for depression on cognitive functioning in the
elderly had not been fully explored (Abraham, Neundorfer, &
Currie, 1992).

In a review of treatment literature, this author did

find several studies that had been designed to impact on

56

57
cognitive functioning and/or depressive symptomatology in
the elderly population but found only two studies that
examined whether there was a relationship between pre-post
levels of depression and cognitive function and type of
treatment used. In one study that is representative of the
treatment literature in general, Gallagher and Thompson
(1983) compared cognitive/behavioral, behavioral, and
insight-oriented treatment techniques in elderly outpatients
and found that participants in all treatment conditions
showed some decrease in feelings of depression but that a
significant percentage (30%) were still depressed following
treatment. Another study by the same authors provided
cognitive/behavioral and insight-oriented group treatment to
elderly outpatients and concluded that there had been an
improvement in depressive symptomatology but no difference
in efficacy between the type of intervention.

Two studies found in the literature were particularly
relevant to the present study in terms of choice of
treatment technique. The first, by DeBarry et al. (1989),
examined the effectiveness of cognitive-behavioral versus
meditation-relaxation intervention in a community-dwelling
elderly population. The only statistically significant
reduction from pre- to posttreatment was a decrease in
anxiety; there was no significant effect on depression.
Unfortunately, this study did not examine the level of

cognitive functioning in the population of interest.

58
The second study of interest was conducted by Abraham
et al. (1992) in which the authors examined not only the
effectiveness of treatment on levels of depression but also
the differential impact of treatment technique on cognitive

function. In this study, the researchers examined the

efficacy of cognitive-behavioral therapy, focused visual
imagery therapy, and a control condition on an
institutionalized elderly population. Their results
determined that there was no significant decrease in
depressive symptomatology in the nursing home residents but
did show an improvement in the level of cognitive
functioning for the two active treatment interventions. It
is likely, however, that their sample may have suffered more
severe levels of memory impairment, as studies of the
institutionalized elderly have suggested.

It is clear, as detailed in the literature review
section of the present study, that the relationship between
depression and dementia is complex and that issues such as
the relationship between cognitive performance and
depression remain unresolved. However, this is a
particularly important area of study, since if depression
and memory loss are related in some way, aggressive
treatment of depression and/or memory loss may lead to an
improved quality of life for the community-dwelling elderly.
Data thus far are inconsistent, and it is evident that the

impact of depression on cognition and the impact of memory

59
loss on depression is not yet fully understood. In a recent
study that was conducted after our own protocol was
complete, Fitz and Teri (1994) found no significant
differences between depressed and non-depressed subjects on
a test for dementia and, therefore, no relationship between
dementia and depression.

The purpose of our study was to advance the
understanding of the complex, intertwined problems discussed
in the review of the literature and above by exploring the
differential impact of receiving cognitive-behavioral,
meditation-relaxation, or no treatment on depression and
memory loss in a community-dwelling elderly population.
Depreaaion and Mempry Complaints

Hypothesis one predicted a significant positive
relationship between depression and memory complaints.
Results indicate that the majority of elderly participants
believed they had problems with their memory independent of
depression. Furthermore, there was no statistically
significant relationship between number of memory complaints
on pre- or post-test and depressive symptomatology. Elderly
individuals who were not depressed complained just as much
about problems with their memory as those individuals who
were depressed.

This finding is contrary to the findings of several
studies which determined that complaints about memory are

positively correlated with depression (O’Connor, Pollitt,

60
Roth, Brook, & Reiss, 1990; LaRue, Dessonville, & Jarvik,
1985; Rastan & Rae, 1981; Zarit, Cole, & Guider, 1981). Our
result might be explained in terms of the low percentage of
individuals who were depressed (9%) on pre- and post-
testing. These participants may have had high expectations
of their cognitive ability, and that could be related to a
high premorbid level of cognitive functioning. These
participants may have been overly sensitized to any age-
associated decline because of their long history of using a
high level of cognitive function as evidenced by their
educational achievements.
Treatment of Depreaaionpand Mampmy,Loaa

Hypothesis two predicted that participating in either
cognitive-behavioral or meditation-relaxation workshops
would be significantly more effective in reducing feelings
of depression than receiving no treatment intervention.
Furthermore, it was hypothesized that there might be a
difference in how effective each active experimental
intervention was on levels of depression.

Results indicate that there were not statistically
significant differences between the type of treatment used
and a reduction in depressive symptomatology. A trend was
noted when comparing the meditation-relaxation workshop to
the control condition (t(86) = 1.42, p=.16). However, it
should be noted that none of the three conditions made any

statistically significant impact on the level of depression

61
from pre- to post-test.

Moreover, when post-hoc analyses examined whether
active treatment interventions were effective in reducing
depressive symptomatology in those who were initially
depressed or memory-impaired, significant results were not
obtained. Thus, results did not support the hypothesis that
elderly individuals participating in either cognitive-
behavioral or meditation-relaxation groups would feel less
depressed than those receiving no treatment.

These results are not totally unexpected when one
recalls the study conducted by Gallagher and Thompson (1989)
in which 30% of elderly participants in group psychotherapy
were not significantly less depressed following group
psychotherapy. Providing additional support for the results
of the present study are those of DeBarry et al. (1989) who
examined the effectiveness of group psychotherapy in
treating depression in the elderly and concluded that there
was no significant reduction in symptoms following
treatment.

Hypothesis three predicted that participating in either
cognitive-behavioral or meditation-relaxation workshops
would be significantly more effective in reducing memory
impairment than receiving no treatment. Furthermore, it was
hypothesized that there might be a difference in how
effective each active experimental intervention was on

levels of cognitive function.

62
Results indicate that there was no statistically
significance difference between the type of treatment used
and improvement in memory. One trend was noted. The
cognitive-behavioral workshop appeared somewhat more

effective in improving cognitive functioning than not

treating at all (t(94) = -1.67, p=.098). However, none of
the three experimental treatment conditions produced any
statistically significant improvement in level of cognitive
functioning.

Moreover, when post-hoc analyses examined whether
active treatment interventions were effective in improving
cognitive functioning in those who were initially depressed
or initially memory-impaired, significant results were not
obtained. It made no difference whether participants were
not depressed or were mildly to severely depressed;
intervention of any kind did not affect overall level of
cognitive function.

In a study similar to ours that examined the impact of
treatment on depression and cognitive functioning, Abraham
et al. (1992) found no alleviation in feelings of depression
but did find that cognitive performance in their elderly
participants improved. However, a significant limitation to
the generalization of Abraham et al. results is that their
sample was drawn from a group of elderly individuals who
were institutionalized in a nursing home.

Memory Loss and Depression

63

Hypothesis four predicted that there would be a
significant positive relationship between depression and
memory loss. Results indicate that there was not a
statistically significant relationship between depression
and memory loss. Elderly individuals who were depressed did
not have significantly more memory impairment that those who
were not depressed, and severity of depression was not
correlated with severity of dementia. In fact, on tests of
cognitive function, the majority of this studies’
participants scored in the normal range on both pre and
post-tests. Furthermore, on the questionnaires that
assessed level of depression, the majority scored in the
normal range on both pre- and post-tests.

Treatment of Memory Complaints

Hypothesis five predicted that participating in either
cognitive-behavioral or meditation-relaxation workshops
would be significantly more effective in reducing the number
of memory complaints than receiving no treatment.
Furthermore, it was hypothesized that there might be a
difference in how effective each active experimental
intervention was on number of memory complaints.

Results indicate that statistical significance was
achieved for all three treatment conditions--cognitive-
behavioral, meditation-relaxation, and waiting list.
Participants in each of these experimental conditions

complained significantly less of problems with their memory

64
after 12 weeks of intervention or waiting. Therefore, we
cannot be sure that change was a function of the treatment
intervention. Change in complaints may have been based on
the expectation that participating or eventually being able
to participate in a group would improve cognitive
functioning.

In attempting to determine whether there were any
differences between treatments, it was found that none of
those treated using cognitive-behavioral techniques felt
that their memory had gotten worse, while several
individuals in the other two treatment conditions agreed
that their memory had deteriorated even after treatment.
This result only approached statistical significance.
Multiple Regreaaion

Hypothesis six predicted that memory loss, depression,
memory complaints, and type of treatment would fit a
regression model and that the model would predict
improvement in cognitive functioning and would show that the
variables mentioned correlated with improvement in cognitive
function. Results indicate that none of the variables fit
into a step-wise or multiple regression model. When trying
to predict treatment outcome, it was found that type of
treatment, level of depression, level of memory loss, age,
and level of education did not correlate with improvement in
overall level of cognitive function.

Limitations and Implicationa for Future Research

65

A discussion of the results must include a critical
review of the methods used in this study. The catchment
area from which this sample was drawn was believed to
provide a representative sample of relatively high-
functioning older adults. Analysis of the results indicated
that our sample was more highly educated than would be
expected for this population. The average participant had
completed one year of college or vocational/trade school,
13% had graduated from college, and 7% had at least 20 years
of education. It is likely that the level of premorbid
cognitive function in this sample may have been higher than
that of a less educated sample of community-dwelling
elderly, thus making it more difficult to show a
statistically significant difference between pre-post
treatment level of cognitive function compared to a less
functional elderly sample.

Yet it is naive to assume all elderly dwelling in the
community are alike. All subsets of the community-dwelling
elderly must be evaluated and treated, because, as was
indicated by our results, even individuals who function at
an extremely high level can still suffer from memory loss
and depression. What may be important about this study then
is illuminating the fact that a very functional, highly
educated older adult population may need to have
interventions tailored to their more sophisticated overall

level of functioning.

66

This leads to a discussion of the interventions used in
this study. It possible that the lack of results could have
been a function of the laboratory nature of the memory and
relaxation training. Significant improvement in cognitive
functioning may have occurred if the interventions had
utilized practical "everyday" memory tasks, which would be
of more interest to the participants. In addition,

treatment may have been more effective if our group leaders

In; A
n
I

had some individual contact with the participants prior to
the workshop so that rapport, a crucial element in
therapeutic change, could have been developed.

Two additional limitations of this study dealing with
instrumentation must be mentioned. First, although many
instruments exist for detecting dementia and depression in
the elderly, diagnostic evaluation of these two conditions
is still problematic. The objective of any type of
assessment is to resolve nonspecific symptoms into specified
target symptoms and to formulate a treatment plan, an
approach this study attempted to facilitate. However, the
tests used in this study to determine whether or not a
participant suffered memory loss may not have been sensitive
enough for our high-functioning sample.

A better method of determining level of cognitive

 

functioning may have been to first test all participants
with the SDAT battery, thus diagnosing whether an individual

had suffered a gross impairment in cognitive functioning,

 

67
and then to administer a more sensitive measure of cognitive
functioning, such as the Mattis Dementia Rating Scale or
Wechsler Memory Scale, to only those participants who scored
in the demented range of the SDAT. The Mattis Dementia
Rating Scale would have provided not only an indication of
how mild to severe dementia was but also would have provided
information on the exact nature of the cognitive deficit,

thus ensuring a more sensitive assessment of improvement in

 

any area of cognitive functioning after treatment.

Using a tool that identified specific areas of
cognitive impairment may have also facilitated the
development of a more effective treatment intervention.
Therefore, although the SDAT battery used in this study
provided information about overall level of memory
impairment, the Mattis Dementia Rating Scale or Wechsler
Memory Scale may have been a more clinically useful test to
administer to only those participants who scored in the
demented range on the SDAT battery.

The second limitation due to choice of instruments is
also an issue of sensitivity. The nature of the memory
tests used in this study was such that we were not able to
look at the finer, more detailed aspects of memory such as
those measured by the California Verbal Learning Test,
Wechsler Memory Scale, and the Mattis Dementia Rating Scale.
This may be particularly important in a more able elderly

population where changes may be smaller and more difficult

68
to detect when using more gross measures like the Senile
Dementia of the Alzheimer Type battery and the Mini Mental
State Examination.

In addition, some might see the use of self-report
depression inventories as a limitation of the study.
However, in examining the level of depressive symptomatology
in our sample, it would appear that our findings agree with E
those of other researchers who have studied depression in 1
the community-dwelling elderly. Oxman and Emery (1993)
found that depression in this population is far less
prevalent than reported in earlier studies of the elderly.
This may be due to the fact that earlier studies were
conducted with those elderly who were easiest to recruit--
namely those who were institutionalized or were being seen
in medical or psychiatric outpatient settings.

The occurrence of symptoms of depression in the elderly
is generally found to be between 13% to 15%, while our study
found that only 8% to 9% were moderately to severely
depressed before treatment. There are several explanations
for the low report of depressive symptomatology in our
sample. Newmann (1989) suggested that the elderly who
volunteer to participate in research are often more
optimistic. It is also highly probable, given that our
participants were so high functioning, that the sample was
biased towards the psychologically healthy individual,

although it could also be argued that this type of

 

69
individual is in fact more representative of the community-
dwelling elderly in general as noted above by Oxman and
Emery (1993).

A final limitation of this study involves data
analysis. Results indicate that the variables of interest
did not fit a regression model. Our predictor variables had
relatively small variability, making it unlikely that
results would be statistically significant. Future studies
may need to include more individuals who are either severely
memory-impaired and/or severely depressed in order to have
predictor variables with larger variances.

Concluaion

Overall, the results of this study did not support the
major hypotheses but were not totally unexpected, given the
complicated and still not clearly defined relationship
between depression and memory impairment. Attempting to
treat depression and memory loss is a relatively unexplored
domain of inquiry, and it is unclear how introducing a
multidimensional variable such as intervention technique
will further influence findings. Our study provided
standardized workshops designed for elderly individuals, yet
none had any statistically significant effect on objective
measures of cognitive function and/or on subjective measures
of depression. Results indicate that many elderly
individuals complain of memory impairment, yet as of this

writing, there is insufficient normative data correlating

70

memory complaints in the highly educated elderly to
performance on memory tests. It seems clear, therefore,
that future research regarding interventions to reduce
depressive symptomatology and memory complaints and to
improve cognitive functioning needs to move forward in order
to advance understanding and more firmly establish
principles of care for the community-dwelling elderly.
Summary

Our study attempted to describe the complicated
relationship between dementia, depression, and memory
complaints in the elderly and then went one step farther in
designing specific interventions geared towards alleviating
feelings of depression and improving cognitive function.
Although there was not a statistically significant
relationship between memory loss, memory complaints, and
depression, it is still important to continue to examine the
relationships between these variables. Furthermore, it is
imperative for health care providers who work with the
elderly to determine what are clinically appropriate and
effective treatment interventions that will improve the
quality of life for those older adults who reside in the

community.

APPENDIX A

71

APPENDIX A

Correlation coefficients for measures used in this study are
presented as follows:

 

Premc Postmc Premmse Postmmse Presdat Postsdat

Premc 1.000 .512 -.094 -.063 .513 .067
Postmc .572 1.000 -.238 -.220 .312 .274
Premmse -.094 -.238 1.000 .575 -.572 -.558
Postmmse -.063 -.220 .575 1.000 -.534 —.516
Presdat .153 .312 -.572 -.534 1.000 .740
Postsdat .067 .274 -.558 -.516 .740 1.000
Prebdi .148 .127 -.199 -.178 .329 .285
Postbdi .274 .233 -.281 —.163 .312 .302
Pregds .310 .286 -.288 -.250 .316 —.067
Postgds .274 .282 -.392 -.239 .322 -.051

Prebdi Postbdi Pregds Postgds

Premc .148 .274 .310 .274
Postmc .127 .233 .286 .282
Premmse -.199 -.281 -.288 -.392
Postmmse -.178 -.162 -.250 -.239
Presdat .329 .312 .316 .322
Postsdat .285 .302 .268 .283
Prebdi 1.000 .704 .689 .607
Postbdi .704 1.000 .719 .766
Pregds .689 .719 1.000 .809

Postgds .607 .766 .809 1.000

 

APPENDIX B

72

APPENDIX B

We have provided a general outline of the protocol for
the cognitive-behavioral workshop employed in this study.
For a more detailed manual please write to Dr. Norman
Abeles, Director; Psychological Clinic, Michigan State
University; East Lansing, Michigan 48823.

Session one included general business, introduction and
ground rules, a get acquainted exercise, a description of
our social learning framework, and a homework assignment.

Session two included a review session, lecture for
self-change skills, and a homework assignment.

Session three included a review session, lecture on
progressive relaxation, and a homework assignment.

Session four included a review session, lecture on
relaxation in everyday situations, and a homework
assignment.

Session five included a review session, lecture on
pleasant activities, and a homework assignment.

Session six included a review session, lecture on
making a pleasant activities plan, and a homework
assignment.

Session seven included a review session, lecture on
controlling thoughts and constructing positive thinking, and
a homework assignment.

Session eight included a review session, lecture on

73
self-instruction, and a homework assignment.

Session nine included a review session, lecture on
social skills, and a homework assignment.

Session ten included a review session, lecture on using
social skills, and a homework assignment.

Session eleven included a review session, lecture on
maintaining gains, and a homework assignment.

Session twelve included a review session, lecture on
making a life plan, and a final pep talk as well as
termination issues.

In addition, everyday memory strategies were offered
during the lecture session of each workshop in order to
facilitate the recall of names, faces, dates, appointments,
where participants had placed things, and the recall of any
information they might forget without using some short-term

memory strategies.

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