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This is to certify that the

dissertation entitled

Cognitive Retraining in the Elderly: The Role of
Depression on Subjective and Objective
Improvement Following Intervention

presented by

Michael William Collins

has been accepted towards fulfillment
of the requirements for

_Eh.D_.__ degree in lsnhlagy—

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aor professor

Nor-an MAbeles, Pb. D.

Date May 13, 1997

 

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COGNITIVE RETRAINING IN THE ELDERLY:
THE ROLE OF DEPRESSION ON
SUBJECTIVE AND OBJECTIVE IMPROVEMENT
FOLLOWING INTERVENTION
By

Michael William Collins

A DISSERTATION

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

DOCTOR OF PHILOSOPHY

Department of Psychology

1997

ABSTRACT

COGNITIVE RETRAINING IN THE ELDERLY:
THE ROLE OF DEPRESSION ON
SUBJECTIVE AND OBJECTIVE IMPROVEMENT
FOLLOWING INTERVENTION

By

Michael William Collins

This study investigated the relationship between depression, imagery-based
mnemonic and relaxation training, and objective and subjective memory. Participants (N =
88) for this study were healthy community dwelling elderly (Mean age = 67) who were
offered periodic assessments of their mood and memory, in addition to a seven session
workshop targeted to teach relaxation and cognitive mnemonic strategies for the relief of
depression and/or memory difficulties. Level of depression symptoms were assessed with
the Beck Depression Inventory (BDI), subjective memory complaints were measured with
the Memory Assessment Clinic Self-Report Scale (MAC-S), and objective memory was
assessed with the California Verbal Leaning Test (CVLT) and the Rivermead Behavioral
Memory Test (RBMT). From our results, it appears that memory remains plastic even in
older age. Our findings, similar to those of previous studies, revealed that group members
significantly benefited in terms of objective memory following the training sessions.
Significant mean differences were found from the pre-test to post-test session for the
CVLT [1(88) = 2.86, p <05] and the RBMT [t(88) = 6.49, p < .05]. Contrary to previous

research in the area of subjective memory, our training efforts were also efi‘ective in

improving memory complaints from the pre-test to post-test session, as determined by the
MAC-S [t(88) = 4.13, p < .05]. Furthermore, the improvement in subjective memory
appeared to be related to a decrease in depression levels on the BDI over the course of the
training sessions [1(88) = -3.95, p < .05]. Our study indicated that a multifactorial training
approach can be equally valuable for different age groups within an elderly sample in terms
of both objective and subjective memory improvement. However, results indicated that
older individuals in the sample (those over the age of 75) benefited less in terms Of
objective memory if they evidenced even mild levels of depression symptomatology at the

pre—test session. Suggestions for fiiture research as well as implications of these findings

were discussed.

 

ACKNOWLEDGMENTS

I wish to sincerely thank the members of my dissertation committee, Dr. Hurley,
Dr. Caldwell, and Dr. Thornton. I appreciate the time and effort you have taken in sorting
through this manuscript and providing the kind of constructive feedback that has made this
a quality piece of work. Not only have each of you contributed to this work, but you all
have played a significant role in my development as a clinician.

I would also like to extend my deepest appreciation to my academic, clinical, and
research mentor, Dr. Norman Abeles. You have played the most significant role in my
maturation as a clinician and researcher. Since arriving at MSU, you have provided me
with a multitude of opportunity and allowed me the freedom to expand my
neuropsychological work into specific interests and passions. Without your guidance,
support, and vision, I would have never achieved the level of competence that I feel I now
possess. You have shaped my career, and for this I will always be grateful.

There are so many others that I wish to thank in helping me to grow and achieve
the unthinkable; the completion of my dissertation and the twilight of my life as a student.
First and foremost, I am truly indebted to the unconditional love and support provided by
my family; especially Mom and Dad, Grammy and Grampy, Terry, the Cyr family, and of
course, my beautiful and compassionate wife, Lynn. The years of encouragement,

patience, and guidance have helped to form my character and given me the tools to be an

iv

 

empathic and caring clinician. Finally, I would like to thank my seven classmates, Dr.
Tony Morrison, the many friends who have smoothed my path in East Lansing, and the

great institution of Michigan State University. I will always be a Spartan.

TABLE OF CONTENTS

LIST OF TABLES ................................................................................................ vii
INTRODUCTION ................................................................................................ 1
Cognitive Retraining in the Elderly: The Method of Loci Technique .......... 6
Cognitive Retraining in the Elderly: The Face-Name Mnemonic .................. 9
Cognitive Retraining in the Elderly: Relaxation and Memory Training ....... 12
Cognitive Retraining in the Elderly: The Effects on Subjective Memory
Complaint ....................................................................................... 15
Subjective Memory Complaint and Cognitive Decline: A Closer Look ....... 20
The Ubiquitous Role of Depression in Subjective Memory Appraisal .......... 22
Depression in the Elderly ............................................................................ 23
The Effects of Depression on Cognitive Performance in the Elderly ............ 25
Hypotheses ................................................................................................. 34
METHOD .............................................................................................................. 37
Participants ................................................................................................. 37
Measures .................................................................................................... 37
Procedure ................................................................................................... 41
RESULTS .............................................................................................................. 44
Everyday Versus Lab Memory Groups ........................................................ 44
Hypotheses ................................................................................................. 45
Post-Hoc Analyses of the Whole Sample ..................................................... 53
DISCUSSION ........................................................................................................ 56
Everyday Versus Lab Memory Groups ........................................................ 56
Hypotheses ................................................................................................. 58
The Effects of the Multifactorial Program on Objective Memory
Improvement ................................................................................... 59
The Effects of Depression on Objective Memory Improvement ................... 60
The Efl‘ects of the Multifactorial Training Program on Subjective
Memory Appraisal ........................................................................... 64
Cognitive Retraining in the Elderly: Cohort-Related Differences in
Performance .................................................................................... 71
Conclusions and Suggestions for Future Research ....................................... 74

Table of Contents (Cont’d)

APPENDIX A ........................................................................................................ 80
Educational Handout #1: Memory Awareness and Evaluation .................... 80
Educational Handout #2: What Happens to Your Memory as You

Get Older? ...................................................................................... 84
Educational Handout #3: Memory and Self Concept .................................. 86
Educational Handout #4: Self-Change Skills .............................................. 90
Educational Handout #5: Pleasant Activities and Depression ..................... 92
Educational Handout #6: Positive Thinking ............................................... 94
Educational Handout #7: Assertiveness ..................................................... 97
Educational Handout #8: Maintaining Your Memory Power ..................... 99

APPENDIX B Beck Depression Inventory ........................................................... 101

APPENDIX C Memory Assessment Clinic SelfReport Scale ................................ 103

APPENDIX D California Verbal Learning Test .................................................... 108

APPENDD( E Rivermead Behavioral Memory Test .............................................. 115

LIST OF REFERENCES ....................................................................................... 119

vii

Table 1
Table 2

Table 3

Table 4

Table 5

LIST OF TABLES

Memory Group Gain Score Mean Differences ....................................... 46

Pre-test and Post-test Means for the Whole Sample on Objective
Measures of Memory ............................................................................ 47

Objective Memory Performance Pre—test to Post-test Mean Score
Differences for the Depression Groups in the Sample ............................. 48

Objective Memory Performance Pre-test to Post-test Mean Score
Differences for the Age Groups in the Sample ........................................ 50

Subjective Memory Performance Pre-test to Post-test Mean Score
Differences for the Depression Groups in the Sample .............................. 54

viii

difl‘erentially vulnerable to the effects of aging, a disruption in the glucose metabolism in
the aging brain, decreased processing resources in the elderly, and a reduced attentional
capacity in the elderly (Craik, 1991). However, whatever the cause, the belief that
cognitive and memory performance declines from young to older adulthood is generally
well supported by experimental studies throughout the gerontological literature.

Additionally, with the fear of such insidious diseases as Alzheimer's disease and
other progressive neurological illnesses, the integrity of one's memory looms large for the
elderly. In fact, more than two thirds of persons over the age of 75 have expressed
concerns about memory loss (Maloney & Bartz, 1982). It has even been suggested that
memory loss is the single biggest threat to independent living in the elderly (Taver, 1984).
It is therefore expected that great fear surrounds the issue of cognitive decline and
memory loss in this population.

In recognition of this well-founded fear, much research has focused on the design
and implementation of relatively brief interventions which may attenuate or even reverse
cognitive decline and memory impairment. Although a host of interventions have been
introduced in the literature, memory aids can be classified into two general categories;
internal and external aids (Harris, 1980). Internal memory aids involve the internal
manipulation of information and usually involve mnemonic training through the use of
visual imagery. External memory aids are viewed as involving the external manipulation
or information and include strategies such as writing reminders to oneself, making a
shopping list, or asking others for needed information. Although training programs

designed to improve memory performance in the elderly have been substantially variable,

programs have been consistent in teaching these internal and/or external memory
strategies. Since a great amount of literature has been conducted in the design and
implementation of these programs, it becomes important to first examine whether these
interventions are successfirl in improving memory in the elderly.

Memory training programs begin with an effort to delineate the everyday memory
concerns of older adults and to define strategies and tasks which may prove to be good
methods for intervention. The typical format implemented to assess the effectiveness a
training program usually consists of (a) a pre-test assessment on memory measures (e. g.
serial recall, prose recall), (b) memory training using imagery based mnemonic strategies
across multiple sessions, and (c) a post-test assessment on equivalent forms of the original
memory tasks. Given the voluminous amount of research conducted in the area of
geriatrics over the last two decades, it is of no surprise that cognitive and mnemonic
training in the elderly has received a considerable amount of attention by researchers. In
considering what should actually be trained, researchers have usually focused on tasks
which appear to resemble some practical memory concern; that is, tasks which have face
validity and are ecologically valid (West, 1989). Furthermore, successful interventions
should be theory driven and provide training in areas which have been shown to be
afi‘ected by age-related cognitive changes (e.g. working memory, explicit memory).

From the literature presented below, it will be shown that memory remains plastic
even in older age. In general, researchers are in agreement that imagery based mnemonic
training programs are successful in improving objective memory in the elderly population.

Two programs in particular, the method of loci technique and the face-name mnemonic,

have been extensively studied and been shown to be effective methods of intervention.
Furthermore, as shown below, there is evidence to suggest that the plasticity associated
with mnemonic training appears to be largely specific to that training, with the largest
treatment gains occurring in groups who are taught relaxation techniques and are trained
to make deeper, more elaborate imagery associations at the time of encoding.

Although the literature will clearly show that older adults improve on objective
memory measures following such training, there is no definitive evidence to suggest that
older adults subjectively perceive these positive changes. As it will be outlined, no study
to date has found a reliable positive effect of memory training on subjective memory
appraisal as tapped by various metamemory questionnaires. With this finding, the utility of
these programs can be called into question.

This study proposes to more closely investigate the objective and subjective
changes following mnemonic intervention by looking at a more distal cognitive and
psychological factor in training outcome, such as depression. Since depression is highly
prevalent in the aging population, it becomes important and necessary to examine how this
mood state affects mnemonic training intervention. The following literature review will
assert that depression has a "shallowing" effect on information processing, learning, and
memory; three processes which are vital in the teaching and understanding of imagery
based mnemonics. Furthermore, outlined research will show that subjective memory
complaints are more a diagnostic indicator for depression than they are for true objective
memory impairment. Given such findings, it is intuitive to suggest that depression may

have a direct affect on both objective and subjective memory following training.

Surprisingly, however, it will be shown that depression has been given little to no
attention in explaining the efiects of this training. This proposed study will closely
investigate the role of depression on these processes and will hypothesize that those who
are not depressed will benefit more in terms of objective memory than has been previously
shown in the literature. Furthermore, it will be hypothesized that nomdepressed elderly
individuals will subjectively perceive these changes, endorsing fewer memory complaints
after training is complete. Ifthese hypotheses prove true, this investigation may provide
important theoretical and practical considerations in the increasingly popular and
important area of memory training in the elderly. Specifically, those who are depressed at
the onset of training may be ill-advised to engage in the intervention since both objective
and subjective memory improvement will be compromised as compared to those who are
not depressed. Clinically speaking, it may be more efl‘ective to treat the depression first
and then provide the mnemonic intervention, since those who have a "normal" mood state
will have been shown to benefit more, both objectively and subjectively, fiom such a
training approach. In addition, other training considerations may be applicable if
increasing levels of depression symptomatology have an impact on training outcome.
With these ideas in mind, what follows is a review of the literature providing background
information in the area of mnemonic training, with a focus on the emcacy of the most
widely used interventions.

It should be noted that the following literature was obtained through searches
utilizing PsychINFO, PsychLIT, and MEDLINE Express, on-line services provided by the

Michigan State University and the University of Michigan library systems.

Cognitive Retraining in the Elderly: The Method of Loci Technique

Smith (1980) has reported that the spontaneous use of organizational schemes,
such as semantic clustering, to encode verbal information decreases with an increase in
age. This encoding deficit directly affects memory since the ability to "ch " or organize
information becomes compromised. Therefore, a systematic intervention focusing on the
organization of verbal material could prove usefirl for any elderly training program.

One such mnemonic used for this purpose is a list-learning strategy called the
method of loci, which requires three general steps (Rose & Yesavage, 1983). First, the
person generates an ordered list of locations from a familiar setting, such as one's
residence or place of work. Once the locations are learned serially, the individual actively
associates a visual image between the first item on the list to be remembered to the first
location along the familiar path (i.e., home or work). Third, the individual proceeds in a
serial order until all the list words are visually associated with different familiar items along
the path. To recall the memory list, the individual simply takes a "mental walk" from each
location to the next "stopping" along the way to first visualize the familiar location and
then to retrieve the actual list item (Yesavage & Rose, 1983). In theory, this mnemonic
provides the individual with an active strategy to organize and encode verbal information,
thus countering age-related deficits which have been found in this area.

Kliegl, Smith, and Baltes (1989) trained both younger and older adults in the
method of loci technique and examined the effects of the training on the ability to encode
and retrieve ordered information. After 26 training sessions, results indicated that older

and younger adults exhibited a large range of developmental reserve capacity and that

older adults were able to repeat, on average, 32 of 40 words that they had seen only once
at a self-paced presentation rate. However, under timed conditions, older adults showed
less training gain when recall occurred under highly speeded conditions. These
researchers concluded that substantial memory plasticity was evident in both age groups.
Rose and Yesavage (1983) examined the effectiveness of the method of loci on
training across young, middle-aged, and older adults. These researchers trained the three
groups of individuals for three days on this technique and used tests of free recall as the
criterion measure. Results of the study indicated that all three age groups demonstrated
significant improvement afier learning the mnemonic, however, it was found that both the
overall level of recall and the amount of improvement displayed decreased with an
increase in age. These researchers attributed this decrease in performance to the
development of encoding and retrieval deficits with age. Nonetheless, Rose and Yesavage
concluded that teaching the method of loci technique could potentially help older adults
firnction better in everyday life and decrease the feelings of hopelessness associated with
cognitive aging decline. Baltes (1992) supported these latter findings through a testing of
the limits approach while also using the method of loci technique. In this study, he trained
both older and younger adults by an additional 18 assessment and training sessions to
explore whether older individuals were able to catch up with younger adults performance
with additional mnemonic practice. Findings from this study suggested that older adults
were able to significantly improve their objective memory performance, however, these
individuals evidenced significant and robust performance deficits when compared with

young adults. Baltes (1992) hypothesized that these findings may have been the result of a

loss in the production and use of mental imagination for operations of the mind as one
grows older.

Yesavage and Rose (1984) examined the effectiveness of a variation in the method
of loci technique for older adults. These researchers taught the standard method of loci
technique to one group and the second group received identical instructions but were also
taught to make a personal judgment of the pleasantness of each visual image association.
Yesavage and Rose predicted that the latter group would benefit from more elaborate
encoding of the visual stimuli, making the stimuli more accessible for later recall. As
predicted, results indicated that the Method of Loci plus judgment group performed
significantly better on a list learning task after three days of training. These researchers
concluded that additional elaboration of visual image associations bolsters the overall
efiecfivmess of the method of loci technique. This finding was also supported by Brooks
(1993 ), who explored difiiculties with the utilization of the method of loci technique. In
his study, older subjects received 6 hours of imagery, judgment, and relaxation pretraining
followed by mnemonic training for either 4 hours regular training or 6 hours extended
training. The subjects were then asked to identify the problematic constituent steps of
learning the technique. Results of the study found that both groups identified difficulty
with abilities called upon in using the technique, but that additional pretraining efforts,
especially in the form of imagery pretraining and forming a judgment of the imagery
stimulus, bolstered the overall effectiveness of the mnemonic technique.

Finally, Anschutz, Camp, Markley, and Kramer (1985) employed the method of

loci technique and examined whether older adults utilized the technique effectively in an

9

ecologically valid setting. These researchers trained older participants in the standard
technique of the method of loci and then verbally presented them with a shopping list of
12 grocery items. The participants then utilized the method of loci to actually shop for
groceries. Four weeks later, a second grocery shopping test was conducted. Results
indicated that participants exhibited near perfect performance in the first grocery shopping
task, however many of the subjects modified their strategies before the second shopping
task. Anschutz et al. (1985) reported that those participants who did not modify their
strategies were more likely to exhibit long-term benefits of the mnemonic training by
remembering more grocery items. The researchers concluded that older adults were able
to generalize the mnemonic to ecologically valid settings at optimal levels, and that using

the mnemonic in its' unadulterated form provided the best results.

Cogm'tive Retraining in the Elderly: The F ace-Name Mnemonic

It is well documented that older adults perform more poorly than young adults on
tests of secondary or long-term memory (Craik, 1977). One practical implication of this
finding is a reduced ability to remember names as one becomes older. In fact, data fiom a
large memory complaint survey indicated that name forgetting was the most frequent of
18 potential memory complaints in the elderly (Zelinski, Gilewski, & Thompson, 1980).
Therefore, an intervention aimed at bettering name recall could prove usefirl for an elderly
cognitive training program.

Another imagery based mnemonic employed solely for this purpose was devised by

McCarty (1980). As outlined by McCarty, this face-name mnemonic requires three

10

general steps; (a) identifying a prominent feature of the persons face (e. g., nose), (b)
registering the person's name and deriving a concrete, high-imagery transformation of the
name (e.g. Wagner becomes a wagon), and (c) associating the prominent facial feature
with the imagery-based name transformation (e.g., visualizing a wagon traveling over the
person's nose). After forming the visual image, one can recall the name at a later date by
utilizing the following steps; (a) identifying the prominent facial feature, (b) using the
feature to retrieve the visual image, (c) identifying the name transformation through the
associated visual image, and (d) decoding the name from the name transformation.
McCarty (1980) showed that a group of students who were trained to use this mnemonic
and were provided the name transformations performed significantly better on a face-name
test than a group trained in rote memorization techniques. Additional findings by McCarty
revealed that all the component steps of the mnemonic were required for its' general
effectiveness, and that the weakest link in the series of instructions was remembering the
transformed name given the prominent facial feature.

Yesavage, Rose, and Bower (1983) examined the effectiveness of the face-name
mnemonic on memory in aged adults. The study was comprised of three groups. The first
group was taught the standard mnemonic technique as outlined by McCarty (1980). The
second group received identical instructions with an additional instruction to judge the
pleasantness of the image association. Participants in the third group were controls since
they were not taught to form an image associating the prominent facial feature with the
name transformation. Findings from the study indicated that those who were taught the

standard mnemonic technique performed significantly better on a face-name test than the

11

controls. Furthermore, those who were asked to judge the pleasantness of the image
remembered more names than the standard group and showed less forgetting on a measure
of delayed recall. Yesavage, Rose, and Bower (1983) hypothesized that by making
affective judgments of the stimulus, the image association of the name was kept in
working memory for a longer period of time, thus enhancing recall.

Gratzinger (1990) used a design similar to the latter study in exploring the role of
personality trait differences in improving face—name recall in older adults. In this study,
three treatment conditions included the standard face-name mnemonic, but differed in the
method of the nonmnemonic training (imagery, relaxation, and imagery and judgment). In
addition, the interventions were assessed in conjunction with the NBC Personality
Inventory. Findings of this study suggested that all subjects improved significantly fi'om
pre-test to post-test in the number of face-name pairs learned. Furthermore, subjects who
scored higher on the openness factor on the NEO scored significantly higher on all
face-name outcome measures, regardless of training condition. Gratzinger (1990)
concluded that the face-name mnemonic was an effective memory strategy and that subtle
personality factors may play a role in determining training outcome success following such
an intervention.

Yesavage and Rose (1984) also looked at the effectiveness of the face-name
mnemonic across different age groups. Young, middle-aged, and older adults were tested
on face-name recall before and after a two-day program which trained individuals in the
standard face-name mnemonic. Findings indicated that all three age groups showed

significant improvement in recall following mnemonic instruction. Furthermore, no

12

significant differences in recall improvement were found between the age groups. The
researchers concluded that the face-name mnemonic was an ecologically valuable

technique which could prove usefirl in cognitive retraining programs for the elderly.

Cogm'tive Retraining in the Elderly: Relaxation and Memory Training

Reviews in the aging literature have noted various impairments in attention and
concentration in the elderly (Kinsboume, 1980). The general implication of Kinsbourne's
work is that attention and concentration deficits have substantial importance in explaining
memory and other cognitive deficits associated with an increase in age. Researchers have
also noted that high levels of anxiety impair attention and concentration ability (Spiegal &
Spiegal, 1978). Therefore, attempts have been made to reduce anxiety and thereby
increase attention and concentration by teaching relaxation techniques to the elderly.

Lichstein (1988) described anxiety as an emotion consisting of three sources of
distress; physiological, cognitive, and motoric. The aggregate influence of these sources
of distress produce an unpleasant experience in the affected individual, resulting in
tenseness, nervousness, and difficulties in concentration. Lichstein (1988) claimed that
relaxation techniques, particularly progressive relaxation, unevenly affects the three
sources of distress comprising anxiety. This researcher theorized that progressive
relaxation affects the physiological response to anxiety and diverts attention away from
troubling thoughts, so that secondary benefits are obtained in the area of memory and
cognition. Therefore, in theory, relaxation training could prove to be an important adjunct

in the cognitive retraining of the elderly.

13

Yesavage (1984) explored the effects of relaxation training in the elderly on the
ability to make use of the face-name mnemonic on a face and name recall task. The
experimental group received relaxation training prior to learning the mnemonic, whereas
the control group was taught a nonspecific method on how to improve attitudes. Results
indicated that the experimental group improved significantly more in face-name recall than
controls. Furthermore, the improvement was significantly correlated with decreased state
anxiety scores, as measured by an anxiety measure. As Yesavage stated, the results
supported the use of relaxation training prior to learning a mnemonic strategy. Since
controls actually became more anxious before the recall task, Yesavage concluded that
learning mnemonics was a "stressful" experience for the elderly, and relaxation training
buffered the associated stressors of learning the mnemonic and performing a recall task.
Overall results of this study were consistent with Spiegal and Spiegal's (1978) finding that
the ability to concentrate is inversely related to anxiety.

A study by Yesavage and Jacob (1984) also studied the effects of relaxation and
mnemonic training on memory, attention, and anxiety in the elderly. These researchers
hypothesized that relaxation training prior to mnemonic training would increase available
memory processing capacity by objectively improving levels of attention. Using the same
design as Yesavage (1984), but including measures of attention, anxiety, and cognitive
interference, these researchers found that subjects who evidenced the greatest reduction in
anxiety and cognitive interference and subsequent increase in attention also evidenced the
greatest performance in recall on a face-name task. They concluded that anxiety in the

elderly interferes with attention and memory through increased cognitive interference.

14

Furthermore, it was concluded that relaxation training was effective in reducing the
amount of anxiety and subsequent interference by increasing attentional processes. They
stated that including relaxation training as an adjunct to mnemonic training increased the
efficacy of the cognitive retraining program.

Finally, a more recent study by Neely and Backman (1995), explored the effects of
a multifactorial memory training program (method of loci, attention and concentration
training, and relaxation training) on the recall of concrete words and the generalizability of
gains across other recall tasks. A total of 46 healthy older adults participated and results
suggested that multifactorial training gave rise to performance gains on the criterion task
that was sustained for six months after the initial post-test. Although there was a
restricted range of generalizability to other recall tasks (i.e., recall of objects, recall of
abstract words), these researchers concluded that a multifactorial training approach was an
effective mode of intervention for older adults. It should also be noted that pretraining
scores alone predicted posttraining scores, whereas age, education, and level of global

functioning did not contribute reliably to the magnitude of outcome gain.

Overall, the teaching of specific mnemonic strategies, such as the method of loci
and the face-name mnemonic, appear to benefit memory performance in the elderly.
Furthermore, the teaching of relaxation techniques prior to the training appears to
potentiate the benefits of this training through the reduction of anxiety and the subsequent

increase of attentional capacities. Additionally, researchers have found that concentration

15

training (Yesavage & Rose, 1983) and imagery pretraining (Yesavage, 1983) bolstered the
effects of mnemonic training in the elderly.

Since objective evaluations of memory improve with mnemonic training, it
becomes important to ask the question as to whether subjective evaluations of memory are
similarly affected. Although intuition would suggest that improved performance outcome
would result in an increased subjective appraisal of one's memory, previous research has
indicated a discrepancy between objective and subjective evaluations of memory in the
elderly (Taylor, Miller, & Tinklenburg, 1992). Furthermore, researchers are in general
agreement that subjective memory complaints correlate more strongly with emotional
states such as depression rather than an actual memory decline (Williams et al., 1987). To
the extent that memory complaints reflect depressed mood, rather than actual deficits in
functioning, are memory enhancement programs effective in increasing subjective memory

appraisal in the elderly?

Cogm'tive Retraining in the Elderly: The Effects on Srfleflive Memory Complaint

Zarit, Cole, and Guider (1981) investigated the effects on mnemonic training on
subjective memory complaints in the community dwelling elderly. Participants were
randomly assigned to a memory training group which utilized visual imagery mnemonic
techniques or a wait-list control group. All subjects were pretested for memory
performance and memory complaints. Results of the training suggested that the
experimental group benefited from training as they outperformed controls on recall tasks.

Furthermore, subjective memory complaints decreased for experimental subjects and

16

increased for controls. However, results also indicated that subjective memory complaints
were not significantly correlated with improvement in performance and that simply
participating in the experimental group improved subjective memory complaints.
Therefore, participation in either group significantly improved memory complaints and this
improvement was independent of objective performance. These researchers concluded
that expectations of improvement, rather than objective performance, was the important
factor in decreasing subjective memory complaints.

In a similar research design, Scogin, Storandt, and Lott (1985) examined the
effectiveness of a self-taught program of mnemonics for older adults complaining of
memory difficulties. Again, results indicated that older adults benefited on objective
measures of memory after the self-taught program. However, there were no significant
changes in subjective memory complaint after training was complete. These researchers
agreed with Zarit et al. (1981) in concluding that expectations about the aging process,
and not objective performance, determined self-appraisal of memory. Specifically, Scogin
et al. (1985) stated that individuals who complained about their memory were more
concerned about the aging process and were sensitive to age-related changes with
memory. Therefore, such individuals performed better on objective measures of memory
after training but remained stable on subjective memory measures, since their expectations
of cognitive decline remained unchanged.

These latter findings are consistent with a more recent study conducted by Best
(1992), who investigated the effects of changing expectations about cognitive abilities on

memory complaint and memory performance in older adults. In this study, participants

17

were assigned to one of four conditions; an expectancy change condition, a memory
training condition, an art discussion control condition, and an evaluation control condition.
Findings suggested that the memory training condition was significantly more effective in
increasing memory performance scores, however, a trend in the data indicated that the
expectancy change condition resulted in fewer memory complaints as compared to the
memory training in isolation. Best (1992) concluded that memory training programs
would benefit from the inclusion of expectancy change discussions along with mnemonic
training intervention.

Hill, Sheikh, and Yesavage (1987) looked at the effects on mnemonic training on
the relationship between recall performance and recall confidence. Participants were
either trained in the face-name mnemonic over a two week period or were wait-listed as
control subjects. Subjects were allowed to participate if there were no acute medical
complications, no signs of organicity (a score of less than 27 on the Mini-Mental State
Examination), and no signs of depressed mood (score of greater than five on the
short-form of the Geriatric Depression Scale). As in previous studies, results suggested
that training in the face-name mnemonic significantly improved face-name recall beyond
that of controls. Furthermore, the researchers found that the relationship between
performance ability and rated confidence was strengthened by memory training, although
training had no direct effect on rated confidence. Hill, Sheikh, and Yesavage (1987)
concluded that the accuracy of memory self-perceptions was facilitated with mnemonic

training rather than overall level of confidence.

l8

Verhagen, Van Ranst, and Marcoen (1993) also researched the effects of
mnemonic training on self-perceptions of memory. These researchers reviewed seven
different memory training programs, each of which consisted of training in imagery-based
mnemonics. Although training across the seven programs was variable, overall results
suggested that participants rated the programs as effective and being useful for their daily
lives. Furthermore, 67% of the subjects rated that most of what they learned was usefirl
and that the process of memory training was considered agreeable by almost all
participants. The researchers found that 41% of the participants indicated that increased
memory awareness was the main efi‘ect of the training. Although subjective evaluations
clearly found that individuals perceived the memory program as beneficial, results from a
metamemory questionnaire indicated that memory training did not change the way elderly
perceive their memory firnctioning, nor did it change the usage of mnemonics. The sole
exception was that after training, subjects reported significantly more instances of
forgetting. Verhagen et al. (1993) concluded that the questionnaire used in the study, the
Memory Functioning Questionnaire, did not tap the aspects of metamemory that change
with memory training. They believed that cognitive changes were more subtle and had
more to do with an increased feeling of control rather than the participant's
self-perceptions of memory problems.

It is of note that the aforementioned studies found no significant effect of memory
training on metamemory or the subjective appraisal of one's memory. This stability of

memory complaint scores after memory training was also found in previous studies using

l9

questionnaires other than the Memory Functioning Questionnaire (Looner & Richter,
1988; Rebok & Balcerak, 1989).

Specific mnemonic techniques, such as the method of loci and the face-name
mnemonic appear to benefit objective memory performance in the elderly. Furthermore,
the pre-administration of relaxation techniques, concentration training, and/or imagery
training appear to augment the benefits of the mnemonics. Although intuition would
suggest that improved performance outcome would result in an increased subjective
appraisal of one's memory, results clearly show that the elderly's subjective appraisal of
memory remains constant after mnemonic training. Therefore, although the elderly are
objectively improving on memory measures, training does not appear to change the way
the elderly perceive their memory functioning, especially if that training fails to address
issues regarding expectancy about cognitive change in older age.

Although the effects of memory training on objective memory functioning has been
examined extensively, the effects of memory training on subjective memory training has
less often been the focus of research (Verhagen et al., 1993). Therefore, no clear
understanding of this relationship exists. However, a considerable amount of research has
been conducted in the associated area of subjective memory and cognitive decline. The
question posed is this: If subjective memory appraisal is independent of objective
improvement in memory, are subjective complaints congruent with a decline in memory

firnctioning?

20

Sgtiective Memory Compla_int_a_r_r_d anitive Decline: A Closer Look

This topic has recently received a considerable amount of attention in the scientific
press. Taylor, Miller, and Tinklenburg (1992) performed a longitudinal study in this area.
Using self-report questionnaires and cognitive tests, these investigators found that at the
individual level, memory performance did not significantly correlate with change in
subjective self report. Larrabee and Levin (1986) also studied memory self-ratings and
objective test performance in a normal elderly sample. These researchers found no
association between memory complaint and objective measures of memory function. They
concluded that subjective memory questionnaires should not be used alone in the diagnosis
of age related disorders when the presenting complaint is memory loss. Kahn, Zarit,
Hilbert, and Niederehe (1975) attempted to clarify the status of memory impairment in the
elderly by assessing the relationship between subjective memory complaints and actual
cognitive functioning and found a marked discrepancy between complaints and memory
performance. They stated that complaints can occur with or without an actual deficit in
memory, and that people who complained about memory sometimes performed better than
those who did not.

Further evidence of this lack of a relationship between memory complaints and
memory decline was given by Williams, Little, Scates, and Blockrnan (1987). Using a
variety of clinical memory tests, they found that memory complaints were not significantly
related to objective memory test performance. Derousene, Alperovitch, Arvay, and
Migeon (1988) studied the interrelationship between severity of memory complaints,

performance in memory tests, and affective status in 367 French 50-80 year olds. No

21

relationship was found between severity of memory complaints and age, sex, educational
level, marital status, living alone or in family, or memory test performance.

Given the above research, one might feel comfortable in concluding that subjective
memory complaints are not indicative of impaired memory functioning. However, one
must be careful in interpreting studies that did not control for pre-morbid functioning.
Christensen (1991) expanded on this point by examining the relationship between
complaint and objective test performance in 20 elderly persons who identified themselves
' as having memory problems. Upon analysis, "memory performance proved poor in those
memory complainers who: (a) considered their memory impairment to be both worse than
their peers; and (b) had a discrepancy between their current level of memory functioning
and that expected on the basis of prernorbid intelligence" (p. 310). However, with this in
mind, analysis of variance did fail to find a relationship between the report of failure of
memory and objective test performance.

It is possible that the objective memory measures used in the above studies were
not successful in delineating those individuals who performed at a much higher cognitive
level in their earlier adult years and who experienced memory decline that landed above
the cutofl‘ scores for "memory impairment." However, the literature fails to report a
significant relationship between memory complaint and poor memory performance. This
consensus is not surprising since memory complaints are especially common in the elderly
and since the incidence and prevalence of actual progressive memory disorders is relatively
low. However, if complaints about memory do not reflect cognitive decline than what are

the correlates of memory complaints and why do they occur?

22

The Ubiquitous Role of Depresysgm in Subjective Memory Apprgigl

The literature suggests that there is a marked incongruity between complaint about
memory and actual memory performance. Complaints can occur with or without an actual
deficit in memory. Perhaps these differences in performance between individuals are a
result of other psychological processes, including depression. Although we have seen
that the relationship between increased memory complaints and actual memory
dysfunction was less than well established (see also, Lamberty & Bieliauskas, 1993 ), there
was an observed relationship between depression and memory complaints.

In the Larrabee and Levin (1986) study mentioned above, factor analysis indicated
that patients' memory self-ratings were primarily related to the affective state rather than
to objective memory performance. These researchers measured depression using the lung
Depression scale. In the Kahn et al. (1975) examination, it was found that while
performance varied with altered brain function, complaint was related to level of
depression, as measured by the Hamilton Rating Scale for Depression. Kahn et al.
concluded that complaints were found to be only a manifestation of depression, not of
cognitive performance. In the Williams et al. (1987) research, memory complaints had a
stronger association with depressed mood, as measured by the Beck Depression Inventory
(BDI), than with performance on memory tests. In the Derousene et al. (1988) study, a
strong correlation was found between severity of memory complaints and scores on a
self-reporting depression questionnaire, even among those with low depression scores.

Since a clinical lore has developed that emphasizes subjective memory complaints

as a diagnostic indicator for depression, it would make sense that subjective memory

23

complaints should decrease as depression lifts. Plotkin, Mintz, and Jarvik (1985) found
that improvements on the Hamilton Depression Scale were significantly related to a
decrease in subjective memory complaints, regardless of whether tricyclic antidepressant

or psychotherapeutic interventions were used.

Overall, researchers are in general agreement that memory complaints are
exacerbated in those who are depressed. In addition, a discrepancy exists between
objective memory and subjective evaluations of memory. It appears that subjective
memory complaints are more a diagnostic sign for depression than an indicator of actual
memory dysfirnction. Therefore, could depression play a similar role in the relationship
between objective memory enhancement and inconsistent subjective memory appraisal?
Researchers are in general agreement that memory complaints are exacerbated by even
low levels of depression (Molinari, 1991). Therefore, it is necessary to closely examine
the role of depression on objective and subjective memory during cognitive training. If
depression is a crucial moderator variable between cognitive decline and subjective
memory complaint than it may be as crucial in looking at the relationship between memory

enhancement and subject memory appraisal.

Dgpression in the Elderly

The general assumption in both the popular and scientific press is that aging is
associated with an increased risk of depression. For example, as Klerman (1983) stated,

"Mental illness, in general, appears to be more prevalent among the elderly than among

24

younger adults; but the incidence of depression is particularly high in persons 65 and
older- not only for depressive disorders, but also for transient symptoms of depression" (p.
3). Others do not fiilly agree with this view. As Newmann (1989) stated, empirical
studies that have investigated the relationship between aging and depression do not show
consistent support for this assumption. Epidemiological data about the incidence and
prevalence of mood disorders in the elderly do not yield a complete and consistent picture
(Blazer, 1983). Newmann's review attributed this inconsistency to diverse measurement
approaches and flaws in design and analysis which make it difficult to draw clear
conclusions regarding the relationship between depression and aging. Nonetheless,

" depression is among the most prevalent health problems of the elderly, occurring for the
first time in about 10 to 20 percent of the population 60 years or older” 0). 87) (Ruegg,
Swerdlow, & Zisook, 1988). The occurrence of depressive symptoms seems to be high
in the elderly ranging from 5 to 40 percent (Lamberty & Bieliauskas, 1993). Although
traditional views regard depression as having a good prognosis in the general population, a
prospective study of 124 elderly patients showed that only one-third actually had a good
outcome (Murphy, 1983). This study suggested that poor outcome is most clearly
associated with severity of depression, physical health problems, and strenuous life events
such as bereavement and separation. Therefore, as Ruegg et al. (1988) stated, it is critical
that clinicians appreciate the importance of depression in the elderly and be fully aware of
the diagnostic indicators and the standard course of pathogenesis. Elderly individuals

often have much to be sad about, as people around them become sick and die, social and

25

economic limitations often arise, health may be compromised, and commonly prescribed
medications are often associated with sadness and fatigue.

As Lamberty and Bieliauskas (1993) pointed out, depression in the elderly is
different from the classical depressions which occur in younger individuals. According to
the Beck (1974) model of depression, the basic syndrome of depression is classically
described by a cluster of five symptoms: (a) a specific alteration in mood, sadness,
loneliness, or apathy; (b) a negative self-concept associated with self reproaches and
self-blame; (c) regressive and self-punitive wishes; desires to escape, hide, or die; (d)
vegetative changes; anorexia, insomnia, loss of libido; and (e) change in activity level;
retardation or agitation. Lamberty and Bieliauskas (1993) stated that these symptoms may
be inherent in the aging process and that "they are easily confounded by the efl‘ects of age

and illness states common to the elderly as well as of changes due to physiological aging"

(p. 151).

The Efl‘ects of Depression on Cognitive Performance in the Elderly

Considering the prevalence of depression in the elderly, it becomes important to
assess the impact of this mood state on cognitive and memory processes within this
population. Fortunately, a considerable amount of research has been conducted within
this area. For example, a meta-analysis conducted by Hunter and Schmidt (1990) assessed
the impact of depressed mood on memory across nine studies from which 13 effect sizes
were calculated. Point bi-serial correlations across each of these studies indicated that a

negative relationship (r -a_vg = -.360) existed between depressed group and explicit

26

memory ability. Hunter and Schmidt warned that this relationship was potentially spurious
since the nine reported studies did not address the issue of causality within this
relationship. However, these authors concluded that greater memory ability was
associated with healthy groups of older adults while the depressed groups had relatively
poorer explicit memory.

A comprehensive review of the literature conducted by Lamberty and Bieliauskas
(1993) also suggested "small" differences between depressed older adults and normal
patients in the area of cognition. Specifically, a summary of neuropsychological findings
suggested that difl‘erences existed in favor of nondepressed patients for motor-related
tasks and measures of attention. In the area of new learning ability, depressed patients
evidenced mild attentional difficulty, "shallow" encoding of information, decreased
response latency, and adequate encoding of information with serial presentation of
material. In the area of memory retention, these researchers summarized existing
literature by stating that depressed patients showed a near normal rate of forgetting on
delayed recall testing, with recall not significantly different fi'om that of non-depressed
patients. Finally, in the area of language function depressed patients evidenced reduced
verbal fluency.

Relative to the effects of depression on cognitive ability, the main areas of concern
for mnemonic training exist in information processing, learning, and memory.
Weingartner et al. (1981) directly studied depression-related changes in information
processing in older adults. By contrasting the cognitive-memorial performance of

depressed patients with that of normal controls, these researchers found that depressed

27

patients failed to engage in encoding strategies that would maximize the likelihood of
subsequent recall. The researchers concluded that during depressive episodes, older adults
evidenced both qualitative and quantitative changes in how information was processed.
Specifically, events became less memorable since depressed patients appeared to use
incomplete encoding strategies to organize the learned information. More importantly
however, findings suggested that depressed patients were able to benefit and learn when
material was presented in an already organized fashion. In a follow-up study, Weingartner
(1986) examined depressed patients' encoding abilities as a function of the amount of
effort required during the learning task. Findings of this study suggested that depressed
patients were equal to normals when the learning task involved "minimal effort."
However, when the learning task was "effort demanding," depressed patients performed
significantly poorer than normal controls. As a result of these findings, Weingartner
suggested that "biological systems associated with motivation, effort, and arousal ...appear
to be linked to the performance of effort-demanding cognitive operations in depressed
patients" (p.223). As Lamberty and Bieliauskas (1993) stated, findings across other
similar studies have been fairly consistent in their findings. Therefore, in summary, as
learning tasks become more diflicult and "effort demanding", depressed patients evidence
a reduced ability to effectively encode and process learned information that would
maximize the likelihood of subsequent recall.

As Yesavage (1985) noted, mnemonic training is a demanding task since older
adults find it especially difficult to produce and remember visual images and visual imagery

associations. Furthermore, Yesavage, Sheikh, Friedman, and Tanke (1990) stated that

28

with mnemonic training there was substantial variability in response to treatment since
elderly subjects evidenced difliculty in applying mnemonic strategies. In short, researchers
are in general agreement that mnemonic training, with or without auxiliary training in
relaxation and/or visual imagery, is a demanding process which requires "considerable"
cognitive effort and mental awareness. In light of the finding that older depressed
individuals evidence encoding dimculties in "effort demanding" tasks, it is intuitive to
suggest that level of depression may be a predictor of mnemonic training success.

Since depression is "inherent" in the aging process and is highly prevalent in those
over the age of 65 it becomes necessary to closely examine how this mood state affects
both objective and subjective memory during cognitive training in the elderly. In
reviewing the literature on mnemonic training in the elderly, it is clear that depression has
not been given enough attention in explaining the effects of this training.

For instance, in those studies previously reviewed which examined the effects of
the method of loci on objective memory performance (Kliegl, Smith, & Baltes, 1989; Rose
& Yesavage, 1983; and Yesavage & Rose, 1984), depression was not a measured variable
and therefore not considered in the analysis of the data. Similarly, in those studies which
examined the effects of the face-name mnemonic on recall (McCarty, 1980; Yesavage &

Rose, 1983; and Yesavage, Rose, & Bower, 1983) measurement of depression was not

considered as a moderating variable. In looking at the effects of relaxation training on the

effectiveness of mnemonics in the elderly, both Yesavage‘s (1984) study and Yesavage and
Jocob's (1984) study screened for depression before selecting participants. Those with

scores of greater than 12 on the Geriatric Depression Scale were excluded from both

29

studies. Therefore, the effects of depression on recall performance was not examined.
Similarly, Yesavage's study on imagery pretraining and memory training (1983) and
Yesavage and Rose's (1983) study on concentration training and mnemonic training used
similar exclusionary criteria for depression in selecting their participants. Therefore, in
these studies depression was either controlled for or not a considered a factor in the
performance outcome. In short, the above findings of memory improvement after
mnemonic and relaxation training can only be generalized to a nondepressed group of
elderly.

In looking at the effects of mnemonic training on subjective memory appraisal,
researchers have generally concluded that depression is not a moderating variable in the
cognitive training-subjective memory relationship (or lack thereof). In the Scogin,
Storandt, and Lott (1985) study, the researchers concluded that memory performance
improved with mnemonic training but the training had no effect on subjective memory
complaint or on depression levels. Level of depression was measured using the lung
Self-Rating Depression scale and results suggested that depression levels and subjective
memory remained stable from pre to post test in both the high and low memory complaint
group. It was concluded that training had no effect on depression or on subjective
memory complaint. They concluded that complaints about memory did not reflect
depression because neither the high complaint group nor the low complaint group were
clinically depressed. In the Zarit, Cole, and Guider (1981) study mnemonic training again
resulted in improved objective memory performance. Furthermore, improvements in

subjective memory occurred but this improvement was independent of the type of training

3O

administered since both the control group (current events discussion) and experimental
group improved subjectively. Therefore, participation in a group was sufficient to reduce
subjective complaints but it was "not clear" that the mnemonic training resulted in the
subjective improvements. In this study, it was interesting to note that depression did have
a minimal, but significant relation to subjective complaints of memory. However, since the
improvement in subjective memory was not specifically attributed to the mnemonic
training, this finding was not discussed.

In the Verhaeghen, Van Ranst, and Marcoen (1993) review it was found that
participants regarded mnemonic training as an agreeable experience that was relevant to
their daily lives. However, in the seven studies reviewed there was no measurable effect
of mnemonic training on the Memory Functioning Questionnaire, a measure which
assessed subjective memory complaint. The only significant finding was that individuals
reported an increase in forgetting after the mnemonic training. Again, it is interesting to
note that depression was not a measured variable in all of the seven studies reviewed.
These authors attributed the stability of the metamemory scores to the lack of sensitivity
on the metamemory questionnaire, suggesting that subjective changes are more subtle and
may have more to do with feelings of control than with the perception of memory
problems.

The present study proposes to investigate the relationship between depression,
imagery-based mnemonic and relaxation training, objective memory, and subjective

memory in greater detail. The literature reviewed has suggested that mnemonic training

31

programs improve objective memory performance in the elderly. However, similar
programs have been shown to have little effect on subjective memory appraisal.

In taking a closer look at studies conducted in the area of mnemonic training and
objective memory performance, it was found that depression was either not considered as
an outcome variable or controlled for when selecting participants. Therefore, the
generalizability of work done in this area is limited since depression is highly prevalent
within the elderly population. Furthermore, it is possible that elderly individuals who are
depressed have a reduced capacity to benefit from nmemonic training since the aging
literature clearly suggests that depressed mood has a compromising affect on the encoding
processes of older adults in "efl‘ort demanding" tasks (Weingartner, 1986).

Verhaeghen, Marcoen, and Goossens (1992) recently conducted a meta analysis in
the area of improving memory performance in the aged through mnemonic training. In
this study, a total of 33 studies were reviewed. Using treatment gain as the criterion
measure, these researchers found that visually-based mnemonic training in the elderly
enhanced performance reliably more than either re-testing or placebo treatment.
Furthermore, results of the meta-analysis indicated that treatment gains were largest when
subjects were younger, when pretraining was provided, when sessions were relatively
short (<1.5 hrs), and when training was provided in groups. Overall, Verhaeghen et al.
(1992) examined 13 variables which could have influenced pre-to—post treatment gains.
However, level of depression was not included in this list of predictor variables.
Therefore, the efl'ects of depression on objective memory improvement after mnemonic

training is unknown at the present time. It is possible that a more distal factor, such as

32

mood state, has a direct afl‘ect on the ability to benefit fi'om mnemonic training. More
specifically, depression may be responsible for problems in the acquisition, retrieval, or
application of the mnemonic training. Considering the prevalence of depression in the
elderly and the generally accepted finding that depression directly affects encoding, it is
clear that the afl‘ects of depression on mnemonic training outcome needs to be closely
examined.

Furthermore, improvement in subjective memory should become an important
focus for memory training programs. From the literature reviewed, it is clear that
mnemonic training enhances objective memory in the aged. However, no study to date
has found a reliable positive effect of memory training on subjective memory as tapped by
various metamemory questionnaires. With this finding, the question of whether the
effects of mnemonic training are of suflicient magnitude to warrant the training efl‘ort can
be raised. Ifthe elderly do not subjectively perceive positive changes in their memory
after training in mnemonics, of what utility are the measurable changes in objective
memory?

From the literature presented, it is clear that a relationship exists between
subjective memory complaint and depression. However, a paucity of research exists
looking at the role of depression on subjective memory enhancement. Since mnemonic
training provides interventions specific to memory and not to depression, those with
higher levels of depression may not feel as though they benefited from the training.
Conversely, participants with lower levels of depression may feel the training was directly

applicable to their memory concerns which would result in a more favorable subjective

33

appraisal. The present study is designed to document whether such an interaction exists,
and to examine the role of depression on subjective memory after mnemonic training. As
Verhaeghen et al. (1992) noted from the findings of his meta-analysis, "nothing can be
inferred about the impact of mnemonic training on everyday memory performance or on
metamemory" (p.250). In considering depression as a potential moderator of this
relationship, this study will take an additional step in addressing these concerns.

As reported by Yesavage (1985), most of the studies in the area of improving
memory via mnemonic training show wide variability of training results between
individuals. However, little is known about the predictors of response to training. In light
of the preceding discussion, the purpose of this study is to assess whether measurable
levels of depressed mood negatively affect the impact of mnemonic and relaxation training

on both objective and subjective memory.

34

Hypotheses

Based on the findings described in this summary, the following hypotheses are
proposed:

1. Group members who receive mnemonic and relaxation training will improve
significantly on objective measures of memory. Operationally, this will be tested by
assessing the difl‘erence between pre-test and post-test performance on two objective
memory measures assessing total recall. The memory measures employed will be the
California Verbal Learning Test (CVLT) and the Rivermead Behavioral Memory Test
(RBMT).

2. As levels of depression increase in group members at pre-test, objective
memory benefits associated with mnemonic and relaxation training will significantly
decrease fi'om pre-test to post test. Operationally, this will be tested by measuring
depression at pre-test with scores on the Beck Depression Inventory (BDI) and total
memory recall at the pre and post test sessions with the CVLT and RBMT. Following
Beck's (1987) interpretive guidelines for the Beck Depression Inventory (BDI), three
depression groups will be delineated. Participants in the normal depression range will be
those who score between 0 and 9 on the BDI at pre-test. Participants who score between
10 and 19 will be classified as moderately depressed. Finally, those who score 20 and
above on the BDI will be classified as severely depressed.

3. A significant positive relationship will exist between subjective memory

complaint and depression. Operationally, this will be tested by assessing the relationship

35

between a subjective memory measure, the Memory Assessment Self-Report Scale
(MAC-S) and the BDI.

4. Group members receiving mnemonic and relaxation training with normal levels
of depressive symptomatology measured at pre-test will improve significantly from
pre-test to post-test on a subjective measure of memory. Operationally, this will be tested
by measuring depression at pre-test with scores on the BDI and measuring subjective
memory at pre-test and post-test with the MAC-S. Again, following Beck’s interpretive
guidelines for the Beck Depression Inventory ( 1987), participants in the normal depression
range will be those who score between 0 and 9 on the BDI at pre-test.

5. Cohort related differences in improvement will be found in total memory recall
following mnemonic and relaxation training. A young/old age group will be defined as
those under the age of 65, a moderate/old age group will be defined as those between the
ages of 66-75, whereas an old/old age group will be defined as those over the age of 75.
It is hypothesized that the young/old age group will significantly outperform the
moderate/old and old/old age groups. Total memory recall will be measured using the
CVLT and the RBMT. In addition, a separate analysis will be done with age treated as a
continuous variable. It is hypothesized that a significant negative relationship will exist
between age and objective memory improvement fiom pre-test to post-test. The
differences between the two analyses will be discussed.

6. Old/old age group members who are in the normal range for depression will
benefit significantly more on objective memory measures following mnemonic and

relaxation training than will young/old and moderate/old age group members who are in

36

the severe range of depression. Total memory will be measured with the CVLT and the
RBMT. Using the criteria delineated by Beck (1987), normal depression will be defined
as scoring between 0 and 9 on the BDI at pre-test and severe depression will be defined as
scoring above 20 on the BDI at pre-test. Again, a separate analysis will be completed
with age treated as a continuous variable rather than as three distinct groups. Within each
depression group, we will look at the relationship between age and memory improvement.
It is hypothesized that age and memory improvement will correlate more significantly in
the normal depression group than in the severe depression group. Any differences in the

analyses will be discussed.

METHOD

Participants

The participants (n=88) for this study were selected from an ongoing Michigan
State University (MSU) Psychological Clinic Aging Research Project. They were a subset
of community dwelling elderly recruited to volunteer by advertisement through senior
citizen groups, senior nutrition sites, and rnid-Michigan retiree groups. Each individual
was offered two assessments of their mood and memory, as well as a seven-session
workshop targeted to teach relaxation and cognitive strategies for the relief of depression
and/or memory difficulties. This pool contained protocols of 55 women and 33 men,
ranging from 47-89 years old (M = 67.2; SD = 8.8), with a mean education of 14.8 years

(SD = 2.9).

Measures
1. BeriDepression Inventory (BBL)

The BDI is a self-rating instrument which measures depression. It consists of 21
items with four graded statements relating to the severity of the symptom. Recent
literature (Karanci, 1988) indicated that the BDI taps afl‘ective, motivational, cognitive,
and somatic symptomatology of depression. Karanci stated that although the BDI total

score has shown good sensitivity and specificity in detecting depression in medical

37

38

patients, several researchers have objected to using total BDI scores for medical patients.
Karanci noted that the somatic/vegetative symptomatology tapped by the BDI may be
by—products of the physical illness. Karanci's study of patterns of depression in medical
patients, found that the somatic/vegetative symptomatology of depression can be partially
accounted for by greater age, illness severity, and attributions to nonpsychological causes.

A cutting score between 14 and 15 points was recommended to identify the
presence of significantly depressed mood by Beck and Beamesderfer (1974). Later, Beck
(1987) recommended using scores on the BDI to delineate ranges of depressive
symptomatology. Specifically, established interpretive guidelines suggested that scores
ranging fiom 0-9 were in the normal range of firnctioning, scores ranging from 10-19
resulted in minimal to mild levels of depression, and scores of 20 and above resulted in
moderate to severe levels of depression.

Results of studies suggested that the BDI has respectable internal consistency and
stability for use with the elderly. For example, there was a positive relationship between
conventional cut off scores on the BDI and selected diagnostic classifications of the
Research Diagnostic Criteria (Spitzer, Endicott, & Robins, 1978) for detection of major
and minor depressive disorders. Only 16.7% were misclassified by customary BDI cutoff
scores (Gallagher, Nies, & Thompson, 1983). Furthermore, the concurrent validity of the
BDI, when correlated with another depression measure, the Geriatric Depression Scale,
was .85 with elderly medical outpatients (Norris, Gallagher, Wilson, & Winograd, 1987).
These results suggested that the BDI can be used as a screening instrument for the

identification of clinically depressed elders.

39

2. Memogz Assessment Clinic Self-Report Scale (LILAC-S)

 

The MAC-S is a relatively new scale which assesses the subjective domain of
memory complaints. This revised questionnaire contains 21 ability items and 24 frequency
of occurrence items. Example of factors include remote personal memory, numeric recall,
word recall/semantic memory, attention and concentration, facial recognition, etc. Factor
analysis demonstrated the usefiilness of the MAC-S factors in a sample of 1106
participants. It has a large normative base that covers the adult range of 18-92 years.
Data has been provided showing the concurrent validity of this new self-report scale.
Results suggested significant associations between self-rated and objectively measured
memory. Overall, the percentage of shared variance between the MAC-S and computer
simulated objective memory tasks ranged from 27.0% to 29.4% (Larrabee et al., 1991).

Youngjohn, Larrabee, and Crook (1992) examined the test-retest reliabilities and
practice effect magnitudes of the MAC-S battery and five traditional neuropsychological
tests among 115 persons and reported significant practice efi'ects at reevaluation. The
test-retest reliabilities were equal to the other traditional neuropsychological measures but

the traditional measures were superior in measures of attention and concentration.

3. *California Verbal Learning Test (CVLT)

The CVLT is a test of verbal learning and memory. Participants are presented
with a 16 item grocery list five times. This list is comprised of four items representing
four different categories; tools, spices and herbs, clothing items, and fiuits. The task

measures the immediate, short delay, cued recall, long delay, and free recall of the

40

presented information. In addition, general learning abilities and learning strategies can be
assessed using this instrument. For the purposes of this study, we are primarily interested
in the number of words learned during the immediate and short delay acquisition period.
Delis, Kramer, Freedland, and Kaplan (1988) conducted a factor analysis of CVLT
scores utilizing normal subjects. Results indicated a six-factor solution; including,
acquisition rate, general verbal learning, learning strategy, response discrimination,
proactive efi‘ect, percent primary, and recall recency. These researchers also conducted an
analysis of the normative sample and cited a coefficient alpha of .74, a split-half reliability

of .63, and test-retest reliability of .59.

4. Rivermead Behavioral Memory Test (RBMT)

The RBMT is a brief (20 minute) test of everyday memory problems. \Vrlson,
Cockburn, Baddeley, and Hioms (1985) reported that the test was designed to have good
face validity, monitor memory change over time, and tap ecologically valid memory
problems. As these researchers reported, the test is a bridge between laboratory-based
measures of memory and assessments obtained by questionnaire and observation. Twelve
components comprise the test, including tasks such as remembering an appointment,
picture recognition, remembering a new route, remembering a newspaper article
(immediate and delayed conditions), facial recognition etc. These tasks were selected on
the basis of observations made by these clinicians on brain injured patients and memory
difficulties reported in a study of head injured people (Sunderland, Watts, Baddeley, &

Harris, 1986).

41

Wilson, Cockburn, Baddeley, and Hioms (1988) assessed the validity of the
RBMT by correlating scores to performance on existing tests, to subjective ratings from
patients, and to observations by therapists of memory lapses. Results indicated that
patients evidenced substantially lower scores than controls, that the RBMT can broadly be
regarded as measuring overall memory performance when assessed in terms of existing
tests, and that subjective ratings correlated strongly with RBMT scores. Overall, these
researchers concluded that the RBMT was a valid test of memory and provided a good
estimate of the likelihood that a patient would encounter everyday memory problems.

Furthermore, interrater reliability was established by having 40 subjects scored
separately but simultaneously by two raters. Results indicated a 100% agreement
between the raters for both scoring procedures (Mlson et al., 1989). Finally, parallel form
reliability was also established by these researchers by giving two versions of the test to
118 patients. The correlation between the two scores was .78 for the Screening Score,
and .85 for the Profile Score. The authors concluded that the RBMT was a reliable test of

everyday memory problems.

Procedure

Participants were assessed on the depression measure and both memory measures
on a pre-training and post-training occasion at approximately a three month interval.
These tests were administered as part of a larger study designed to assess mood and
memory firnctioning. All testing was carried out by previously trained evaluators enrolled

in MSU's clinical psychology programs. Participants were not paid for their participation.

42

However, each individual was told they would be receiving feedback on their mood and
memory status, as well as receiving the seven session workshops targeting at improving
memory difficulties. Each testing session required between one-and-one-half and two
hours. All tests were initially scored by the battery's administrator. However, the tests
were re-scored by an additional evaluator to ensure accuracy.

A session by session (7 sessions total) training manual directed the memory and
relaxation training. Again, clinicians enrolled in MSU‘s clinical psychology program
directed the training programs. Consistent with the findings by Verheaghen, Marcoen,
and Goossens (1992), memory training was conducted in groups of 4-9 individuals over
the age of 55 with each session lasting for approximately one hour.

Sessions one and two began with an educational instruction and a discussion of
memory loss and its association to aging. The remainder of the sessions were devoted to
teaching the method of loci technique, face-name mnemonic, relaxation training, attention
and concentration training, and other age-related memory strategies. In addition, group
members were provided with educational handouts discussing topics such as memory
awareness and self-evaluation, age-related memory decline, memory and self-concept,
self-change skills, pleasant activities and depression, positive thinking, assertiveness, and
maintaining your memory power (See Appendix A). Each participant received written
instructions on the method and techniques of the method of loci, face-name mnemonic,
and relaxation training. The method of loci training also included four sets of commonly
used words to be learned by the subjects. The reinforcement for the groups entailed the

repetition of tasks, positive feedback, and homework on the application of the mnemonics.

43

As part of a larger study assessing mood and memory, half of the participants were
taught standard mnemonic techniques, while halfwere trained with everyday applications.
For example, the standard group were taught strategies for learning arbitrary word lists,
while the everyday group were taught strategies for shopping items and errands. Both
groups received the same amount of mnemonic training using the same learning techniques
and strategies. Furthermore, both groups received the same educational handouts

delineating the mnemonic techniques and addressing age-related concerns.

RESULTS

Data analyses were subdivided into three components. First, statistical
comparisons were made between the "everyday" memory group and "lab" memory group
to determine whether one group out-perforrned the other in terms of objective memory
improvement, subjective memory improvement, and level of depression following the
training sessions. Second, the six hypotheses were evaluated. Third, post-hoe analyses of

the overall sample were conducted.

Everyday Versus Lab Memory Groups

As part of a larger study assessing mood and memory, approximately half of the
participants were taught standard mnemonic techniques (a = 38), while the other half were
trained with everyday applications (a = 50). Statistical analyses were conducted to
determine if any significant outcome difl‘erences existed between the groups following
mnemonic and relaxation training. The following variables were examined: objective
memory improvement (i.e., CVLT, RBMT), subjective memory improvement (i.e.,
MAC-S), and level of depression (i.e., BDI). Two sample t—tests were conducted to
determine if individuals in the everyday memory group benefited more or less than
individuals who participated in the lab memory group. Mean differences were assessed on

memory and depression measures between pre-test and post-test performance. As Table 1

44

45

shows, no significant differences were found for either the memory or depression
variables. That is, the everyday and lab memory training groups performed similarly from
pre-test to post-test session in terms of objective memory improvement, subjective
memory improvement, and level of depression.

Therefore, in summary, for the purposes of the current investigation those who
took part in the everyday or lab memory group were combined due to small samples and
since statistical analyses indicated that the treatment effects were not significantly different
between the two groups.

Hypotheses

Hypotheses I. It was predicted that group members who receive mnemonic and
relaxation training would improve significantly on objective measures of memory, as
measured by the total raw score on trials 1-5 on the CVLT and the sum of the
standardized scores on the RBMT. Hypothesis I was supported. Operationally, this was
tested by assessing the difference between pre-test and post-test performance on these
memory measures. A one-sample _t_-test was conducted to assess the mean differences on
memory between pre-test and post-test performance. Significant mean differences were
found for the CVLT [1(88) = 2.86, p < .05] and the RBMT [1(88) = 6.49, p < .05]. That
is, group members significantly improved from the pre-test to post-test session on the
CVLT and RBMT, which are both measures of objective memory. The means and
standard deviations for the pre-test and post-test performances on the CVLT and RBMT

for the whole sample are reported in Table 2.

46

Table 1: Memory Groap Gain Score Mean Differences

 

Variable Mean
California Verbal Learning Test (Trial 1-5 Raw Score)

Everyday 2.2
Lab 4.4

Califomia Verbal Learning Test (Short-Delay Free Recall)

Everyday .84
Lab 2. 1

California Verbal Learning Test (Recognition Hits)

Everyday .27
Lab .58

Rivermead Behavioral Memory Test (Sum of Standardized Scores)

Everyday 1 .4
Lab 1.9

Memory Assessment Clinic Self-Report Scale (Total Score)

Everyday 4.8
Lab 6.7

Beck Depression Inventory (Total Score)

Everyday -1.5
Lab -1.6

11.7
10.0

3.7
3.1

3.0
3.0

2.4
2.3

13.4
13.2

3.9
3.8

.36

.10

.65

.39

.53

.96

 

* Significance at the .05 alpha level
** Significance at the .0] alpha level

47

Table 2: Pre-test and Post-test Means for the Whole Sample on Olfiective Measures of

 

Memogz
Testing Session CVLT RBMT
(Trial 1-5 Total Score) (Sum of Standardized
Scores)
Mean SD Mean SD
Pre-Test 44.2 12.1 18.3 4.3
Post-Test 47.6 14.9 19.9 4.1

 

Hypotheses II. The second hypothesis predicted that as levels of depression increase in
group members at pre-test, objective memory benefits associated with mnemonic and
relaxation training would significantly decrease. Operationally, this was tested by
measuring depression at pre-test with scores on the BDI and total memory recall at the pre
and post-test sessions with the CVLT and RBMT. Following Beck's (1987) interpretive
guidelines, three depression groups were delineated. Participants in the normal range for
depression (a = 61) were those who scored between 0 and 9 on the BDI at pre-test.
Participants who scored between 10 and 19 were classified as moderately depressed (_n =
23). Finally, those who scored 20 and above on the BDI were classified as severely
depressed (a = 4). This hypothesis was tested by an analysis of variance which was
performed to determine the effect of depression level (normal, moderate, severe) on
memory improvement fi'om pre-test to post-test session. Hypothesis II was not
supported. That is, the analysis of variance indicated that none of the three depression
groups were significantly different at the .05 level for pre-test to post-test gain on either

the CVLT or the RBMT.

48

Since only four individuals comprised the severe depression group in the sample, a
larger group was created by collapsing the moderate and severe depression groups into
one "depressed" group. That is, individuals scoring between 0 and 9 on the BDI were
classified as the "non depressed" group (p = 61) and those scoring higher than nine on the
BDI were classified as the "depressed" group (.11 =27). This allowed a comparison
between a depression group with a larger sample size and the "non depressed" group. A
two-sample t-test was conducted to assess the mean differences on memory improvement
from pre-test to post-test between these two depression groups. Results revealed
nonsignificant findings between the depression groups in terms of objective memory
improvement. Nonsignificant mean differences were found for the CVLT [1(88) = .63, p >
.05] and the RBMT [t(88) = -.37, p > .05]. That is, objective memory improvement from
pre-test to post-test as measured by the CVLT and RBMT was consistently nonsignificant
between depression groups as measured by the BDI. The objective memory performance
pre-test to post-test mean score differences for the depressed and non depressed groups

are reported in Table 3.

Table 3: Objective Memory Performance Pre-test to Post-test Maap Score Differences_fo_r
the Mpression Groups in the Sarnple.

 

 

D ression Grou CVLT RBMT
81’ 9 (Trial 1-5 Score) (Sum of Standardized
Scores)
Mean SD Mean _S_12
Depressed Group(l_\l_=61) 3.8 11.4 1.6 2.5
N°“'Dep'essed Group (E = 2.2 9.7 1.8 2.1

27)

 

49

Hypothesis III. The third hypothesis predicted that a significant relationship would exist
between subjective memory complaints, as measured at pre-test by total MAC-S score,
and depression, as measured at pre-test by the total score on the BDI. Hypothesis III was
supported. A Pearson product-moment correlation revealed a significant relationship
between these measures, (1; (88) = -.34, p < .05). That is, people who scored lower on the
MAC-S, indicating subjective difliculties with their memory, scored significantly higher on

the BDI, indicating higher levels of depression.

Hypotheses IV. The fourth hypothesis predicted that group members receiving
mnemonic and relaxation training with normal levels of depressive symptomatology
measured at pre-test would improve significantly fi'om pre-test to post-test on a subjective
measure of memory. A one-sample t-test was conducted to assess the mean differences
on the MAC-S between pre-test and post-test performance for the normal depression
group (r_r = 61). Hypothesis IV was supported. Significant mean difl‘erences were found
for this group of individuals [1(61) = 3.37, p < .05]. That is, group members who were in
the normal range for depression at pre-test significantly improved from the pre-test (_M_=
123.5, S1; = 16.4) to post-test M = 128.4, E = 15.7) session on the MAC-S, which is a
subjective measure of memory. Therefore, these individuals endorsed fewer memory

complaints fi'om the pre-test to post-test session.

Hypothesis V. The fifth hypothesis predicted that age-related differences would be found

in total memory recall fOllowing mnemonic and relaxation training. Two analyses were

50

conducted for this hypothesis. First, a one-way analysis of variance was performed to
determine the effect of age on objective memory improvement from pre-test to post-test.
For the purposes of this analysis, a young/old age group was defined as those under the
age of 65 (p = 37), a moderate/old age group was defined as those between the ages of
66-75 (a = 33), and an old/old age group was defined as those over the age of 75 (p = 18).
Hypothesis V was not supported. That is, analyses of variance indicated that none of the
three age groups were significantly different at the .05 level for pre-test to post-test gain
on either the CVLT (f: .65, p >.05) or the RBMT (f = .22, p > .05). The objective
memory performance pre-test to post-test mean score differences for the three different

age groups are reported in Table 4.

Table 4: Objective Memory Performance Pre-test to Post-test Mean Score Differences for

 

 

the Age Groups in the Sample.
Age Group CVLT RBMT
(Trial 1-5 Score) (Sum of Standardized
Scores)
Mean S_D_ Mean fl;
Young/Old (N = 37) 3.4 11.6 1.6 1.9
Moderate/Old @ = 33) 4.6 9.5 1.5 2.7
Old/Old (N = 18) 1.0 12.3 1.9 2.6

 

In addition, a separate analysis was conducted with age treated as a continuous
variable. It was predicted that a significant negative relationship would exist between age

and objective memory improvement from pre-test to post-test across both memory

51

measures. Using this separate analysis, hypothesis V was still not supported. For the
CVLT, a Pearson product-moment correlation revealed a statistically nonsignificant
relationship between age and objective memory improvement (1 = -.09, p > .05).

Similarly, for the RBMT, a Pearson product-moment correlation revealed a non-significant
relationship between age and objective memory improvement (_r_ = .01, p > .05). That is,
no significant relationship existed between age and pre- to post-test gain on objective

measures of memory following mnemonic and relaxation training.

Hypothesis VI. Hypothesis number six predicted that old/old age group members who
were in the normal range for depression would benefit significantly more on objective
memory measures than would young/old and moderate/old age groups who were in the
depressed range. Objective memory was measured using the CVLT and RBMT and
depression was measured using the BDI. As in the second hypothesis, two depression
groups were defined. Those individuals scoring between 0 and 9 on the BDI at pre-test
were defined as the "non depressed" group (I! = 61) and those individuals scoring greater
than 9 on the BDI were demarcated as the "depressed" group (H = 27). That is, the
moderate and severe depression groups were collapsed into one group of depressed
individuals. Again, by defining depression in this way it ensured a larger sample size for
the depressed group. Two analyses were conducted for this hypothesis.

First, a two-way analysis of variance was performed to determine the effect of
depression level (normal, depressed) and age (young/old, moderate/old, and old/old) on

objective memory improvement from pre-test to post-test. Hypothesis six was not

52

supported using this analysis. None of the main effects of age and depression were
significant for the CVLT (Age: f= .43, p > .05; Depression: _f = .45, p > .05) or the
RBMT (Age: f= 1.42, p > .05; Depression: f: 1.52, p > .05). Also, the two-way
interaction effects of age and depression were nonsignificant for the CVLT (f = .50, p >
.05) or the RBMT (f = .85, p > .05). Therefore, the old/old age group members in the
normal range of depression did not benefit significantly more on objective memory
measures than the young/old and moderate/old age group members who were in the
depressed range.

In addition, a separate analysis was conducted using age as a continuous variable
and looking at the relationship between age and memory improvement within each
depression group. It was expected that a positive relationship would exist between age
and objective memory improvement in the normal depression group and a negative
relationship would exist between these two variables in the depressed group. In the
normal depression group on the CVLT, a Pearson product-moment correlation revealed a
statistically nonsignificant relationship between age and objective memory improvement (I
= .05, p > .05). In addition, in the normal depression group on the RBMT, a Pearson
product-moment correlation revealed a nonsignificant relationship between age and
objective memory improvement (: = .1, p > .05). That is, no significant relationship
existed between age and objective memory improvement in the normal depression group
following mnemonic and relaxation training.

In the depressed group on the RBMT, a Pearson product-moment correlation

revealed a nonsignificant relationship between age and objective memory improvement

53

(1 = -. 1, p > .05). However, in the depressed group on the CVLT, findings revealed a
marginally statistically significant negative correlation between age and objective memory
improvement (1 = -.4, p = .05). That is, as age increases within the depressed group
objective memory improvement from pre-test to post-test on the CVLT significantly
decreases.

Post-Hoe Analyses of the Whole Saanla

First, an analysis of the entire sample was conducted to determine whether those
individuals who participated in the mnemonic and relaxation groups improved fi'om
pre-test to post-test in terms of subjective memory. In hypothesis IV, it was determined
that those individuals in the normal range for depression benefited in terms of subjective
memory. Similarly, when the whole sample was examined it was found that the mean
differences for the group were significantly difl‘erent from pre-test CM= 120.2, _S_I_) = 18.4)
to post-test (M = 126.1, S_Q = 17.5) in terms of subjective memory improvement. A
one-sample t-test indicated significant mean differences from the pre-test to post-test
session in terms of overall subjective memory improvement (1 (88) = 4.13, p < .05). That
is, the overall sample improved in terms of subjective memory following the mnemonic
and relaxation training sessions.

Furthermore, this improvement on subjective memory was consistent between
depression groups. A two-sample t-test between those in the "nondepressed" group as
compared to those in the "depressed" group was conducted in terms of subjective memory
improvement. This analysis revealed no significant differences between groups (1 (88) =

-.92, p > .05). That is, level of depression measured at the pre-test session was not a

54

significant moderating variable in terms of subjective memory improvement fiom the pre-
to post-test session. Therefore, the whole sample benefited in terms of subjective memory
following mnemonic and relaxation training, regardless of the level of depression. The
subjective memory performance (MAC-S) pre-test to post-test mean score differences for

the depressed and non depressed groups are reported in Table 5.

Table 5: Subjective Memory Performance Pre-test to Post-test Mean Score Differences
for the Depression Groups in the Sample

 

Depression Group MAC-S
(Total Score)
Mean _SD
Depressed Group(N=61) 4.8 11.1
Non-Depressed Group (N = 27) 8.2 17.1

 

Second, a multiple regression was conducted to see the impact of age and
depression on subjective memory improvement. Results showed a nonsignificant t-value
for both the age (Beta = .01, t = .09, p > .05) and depression (Beta = .12, t = 1.08, p >.05)
variables. Furthermore, the R-square value for this model was only .01, which leaves 99%
of the variability unexplained. Therefore, neither age nor depression were moderating
factors in terms of overall subjective memory improvement.

Third, an analysis of the whole sample was conducted to determine if group
members improved from the pre-test to post-test session in terms of depression level, as
measured by the BDI. When the whole sample was examined, it was found that the mean

differences for the group were significantly different fiom pre-test (M = 8.2, S1; = 6.7) to

55

post-test (M = 6.6, _SD = 5.1) in terms of overall depression score. A one-sample t-test
revealed significant mean differences in terms of depression level (1 (88) = -3.95, p < .05)
fi'om the pre-test to post-test session. That is, group members significantly improved in
terms of depression level following the mnemonic and relaxation training sessions.

It is noteworthy that Hypothesis 1H revealed a significant positive relationship
between subjective memory complaint and level of depression (I (88) = -.34, p < .05).
That is, people who scored lower on the MAC-S, indicating subjective difliculties with
their memory, scored significantly higher on the BDI, indicating higher levels of
depression. Therefore, it follows that group members significantly improved in terms of
subjective memory since the overall sample improved in terms of overall level of
depression.

Fourth, an analysis of the whole sample was conducted looking at the relationship
between age and subjective memory improvement. A Pearson product-moment
correlation revealed a statistically nonsignificant relationship between age and subjective
memory improvement ([ = -. 1, p > .05). That is, younger individuals showed a slightly
greater increase in subjective memory improvement fiom the pre-test to post-test session.

Finally, an analysis was conducted to determine the degree of relationship between
age and level of depression improvement from the pre-test to post-test session. A Pearson
product-moment correlation revealed a modest sigrnificant negative relationship between
age and depression improvement (1 (88) = .25, p < .05). Therefore, older participants

declined less in depressive symptoms than younger ones.

DISCUSSION

Data analyses were subdivided into three components. First, statistical
comparisons were made between the "everyday" memory group and "lab" memory group
to determine whether one group out-performed the other in terms of objective memory
improvement, subjective memory improvement, and level of depression following the
training sessions. Second, the six hypotheses were evaluated. Third, post-hoe analyses of
the overall sample were conducted. This same format will be used to discuss the findings
of these analyses.

Evmday Versus Lap Memory Groups

Results indicated that the everyday and lab memory training groups performed
similarly from the pre-test to post-test session in terms of objective memory improvement,
subjective memory improvement, and level of depression. Given these results, there was
reasonable evidence to support combining these groups as a whole sample in addressing
the research questions that have been posed.

Consistent treatment effects between the everyday and lab memory groups support
the findings of a meta-analysis conducted by Verhaeghen, Marcoen, and Goossens (1992)
in the area of improving memory performance in the aged through mnemonic training.
These researchers reviewed 33 studies and used treatment gain as the criterion measure.

Overall, Verhaeghen et al. (1992) examined 13 variables which could have influenced

56

57

pre-to-post treatment gains in terms of objective memory improvement. Only four
variables were found to influence treatment gains across these 33 studies. Treatment gains
were largest when the subjects were younger, when pretraining was provided, when
training was carried out in groups, and when sessions were relatively short. Interestingly,
no significant differences could be found in the effectiveness of different kinds of
mnemornic techniques or different types of pretraining. Meta analytic results indicated that
virtually all of the classes of effect sizes for the different mnemonic training programs were
homogenous. Although programs were substantially variable in terms of the stimuli used
and mnemonic training intervention (i.e., method of loci, face-name, intemal-external
strategies), the effect sizes in terms of pre-to-post objective memory gain were consistent.
Given the findings of the Verhaeghen et al. (1992) meta analysis, it is not
surprising that no significant differences in this study were found between the lab and
everyday memory groups. This is especially true considering that the only difference
between groups was the memory stimuli used for training. For example, participants in
the lab memory group were taught strategies for learning arbitrary word lists, while
participants in the everyday group were taught strategies for shopping items and errands.
Both groups received the same amount of mnemonic training using the same learrning
techniques and strategies. These findings suggest that mnemonic techniques generally
provide subjects with an effective strategy to organize and encode the stimulus material
and that changing the memory stimuli to be learned does not have an additional affect on
training outcome. Finally, both groups received the same educational handouts delineating

the mnemonic techniques and addressing age-related concerns. Individuals in both groups

58

were provided with handouts discussing topics such as memory awareness and
self-evaluation, age-related memory decline, memory and self-concept, self-change skills,
pleasant activities and depression, positive thinking, assertiveness, and maintairning your

memory power. For the purpose of replication, these educational handouts can be found

in Appendix A.

Hypotheses

The present study proposed to investigate the relationship between depression,
imagery-based mnemonic and relaxation training, objective memory, and subjective
memory in greater detail. To attain this goal, we first attempted to assess the eflicacy of a
multifactorial training program aimed at improving memory performance in the aged. This
program consisted of visually-based mnemonic training sessions (i.e., method of loci
technique, face-name mnemonic), relaxation training, and an educational workshop aimed
at addressing age-related concerns. The format implemented to assess the efl‘ectiveness of
this training program consisted of (a) a pre-test assessment of memory (i.e., objective and
subjective memory) and level of depression, (b) a seven session group training workshop,
and (c) a post-test assessment on equivalent forms of the original assessment. Consistent
with the findings by Verhaeghen, Marcoern, and Goossens (1992), memory training was
conducted in groups of 4-9 individuals over the age of 55 with each session lasting for

approximately one hour.

S9

The Effects of the Multifactorial Program on Objective Memorflmprovement

The first analysis revealed that the program was successfirl in that group members
improved from the pre-test to post-test session on the California Verbal Learning Test
(CVLT) and the Rivermead Behavioral Memory Test (RBMT), which are both measures
of objective memory. This finding supports the notion that imagery based mnemonic and
relaxation training programs are successfirl in improving objective memory in an elderly
population. Previous research has shown the effectiveness of the method of loci technique
(Anschutz et al., 1985; Baltes, 1992; Brooks, 1993; Rose & Yesavage, 1989; Yesavage &
Rose, 1983; Yesavage & Rose, 1984) and the face-name mnemonic (Gratzinger, 1990;
McCarty, 1980; Yesavage, Rose & Bower, 1983; Yesavage & Rose, 1984) in improving
objective memory in elderly populations. In short, these types of mnemonics may provide
an individual with an active strategy to organize and encode verbal information, thus
countering the age-related deficits which have been found in this area.

Furthermore, it appears that relaxation training may be an efi‘ective supplement to
the mnemonic interventions. Results of this study corroborate previous research that has
shown relaxation training to be an effective mode of intervention in improving objective
memory performance in the elderly (Yesavage, 1984; Yesavage & Jacob, 1984).

Lichstein (1988) has claimed that relaxation training increases available memory
processing capacity by objectively improving levels of attention. Therefore, this type of
training appears to be an important adjunct to the mnemonics since Kinsboume (1980) has

noted various impairments in attention and concentration in the elderly.

60

Overall, it appears that the multifactorial mnemonic and relaxation training
approach used in this study was effective in improving objective memory in an able elderly
population. It is noteworthy that this type of multifactorial approach has less often been
the focus of research, with more studies examining the implementation of a single program
(i.e., method of loci or face-name mnemonic or relaxation training). However, our
findings are in agreement with that of Neely and Backman (1995), who combined the
method of loci technique, attention and concentration training, and relaxation training in
an able elderly population. Similar to our findings, they concluded that a multifactorial
training approach was an effective mode of intervention for older adults in terms of

objective memory improvement.

The Effects of Depression on Objective Memory Improvement

In taking a closer look at studies conducted in the area of mnemonic training and
objective memory performance, it was found that depression was either not considered as
an outcome variable or controlled for when selecting participants (Kleigl, Smith & Baltes,
1989; McCarty, 1980; Rose & Yesavage, 1983; Yesavage & Rose, 1984; Yesavage &
Rose, 1983; Yesavage, Rose & Bower, 1983). Therefore, the efl‘ects of depression on
objective memory improvement is unknown at the present time. However, it is possible
that a more distal factor, such as mood state, has a direct efl‘ect on the ability to benefit
from mnemonic training. More specifically, depression may be responsible for problems in
acquisition, retrieval, or application of the mnemonic training. Considering the prevalence

of depression in the elderly and the generally accepted finding that depression directly

61

afl‘ects encoding, it was clear that the effects of depression on mnemonic training outcome
needed to be closely examined.

The second hypothesis predicted that as levels of depression increase in group
members at pre-test, objective memory benefits associated with mnemonic and relaxation
training would significantly decrease from pre-test to post-test. However, the second
analysis revealed that no significant differences in objective memory improvement existed
between those with normal depression versus those with mild/moderate depression versus
those with severe levels of depression. Irnportantly, however, it was found that our
overall sample was healthy in terms of depression level. Specifically, only four out of 88
individuals in the sample (4%) were classified to be severely depressed. Therefore,
another analyses was conducted looking at individuals with normal levels of depression
versus a larger group of individuals who scored above the normal level of depression, as
determined by Beck's (1987) interpretive guidelines. However, results still revealed
nonsignificant findings between the depression groups in terms of objective memory
improvement from the pre-test post-test session.

Literature in the area of depression and cognitive performance in the elderly have
shown that in "effort demanding" tasks, depressed older adults show mild attentional
difficulty, "shallow" encoding of information, decreased response latency, and reduced
verbal fluency (Hunter & Schmidt, 1990; Lamberty & Bieliauskas, 1993; and Weingartner,
1981). Since mnemonic training can be considered as an "effort demanding" process

which requires considerable cognitive exertion and mental awareness, why does

62

depression level not have a sigrnificant effect on our sample of older adults in terms of
objective memory improvement?

The answer to the above question may have to do with the health of our sample in
terms of depression level. Again, sixty-one of the individuals in our sample (69%) were
classified as having normal levels of depressiorn, according to the interpretive guidelines
for the Beck Depression Inventory (Beck, 1987). Conversely, twenty-three individuals
were classified as scoring in the mild to moderate range for depression and only four
individuals in the sample were classified as severely depressed. By collapsing the
mild/moderate and severe groups into one sample, there were twenty-seven individuals
(3 0%) with measurable levels of depression.

Although epidemiological data about the incidence and prevalence of mood
disorders in the elderly do not yield a complete and consistent picture (Blazer, 1983), the
occurrence of depressive symptoms seems high in the elderly ranging from 5 to 40
percent, depending on the method of measurement (Lamberty & Bieliauskas, 1993).
Ruegg, Swerdlow, and Zisook (1988) have also stated that "depression is among the most
prevalent health problems of the elderly, occurring for the first time in about 10 to 20
percent of the population 60 years of older." Notably, these researchers used the BDI in
their epidemiological survey, defining depression as those who scored greater than 20 on
the measure. Therefore, we can conclude that our sample was not typical of the general
elderly population in terms of level of depression. In essence, we were comparing a group
of individuals who were in the normal range of depression to a group who evidenced mild

levels of depressive symptomatology.

63

In a thorough review of the literature in the area of depression and cognition in the
elderly, Lamberty and Bieliauskas (1993) stated that non-major depression does not
appear to have significant influence on patients’ performance on standard cognitive
screening measures. Moreover, a recent 10-year longitudinal study conducted by Tranel,
Benton, and Olson (1997) indicated that older persons remaining in good health (i.e., no
depression symptoms) evidenced age-related decline in higher order mental capacities,
such as language, intellect, perception, and decision making. Therefore, in our relatively
healthy sample, mild levels of depression may have had a negligible effect on information
processing, learning, and memory, three areas which are critical for mnemonic training.

Furthermore, Weingartner (1981) has found that depressed patients fail to engage
in encoding strategies that maximize the likelihood of subsequent recall. Specifically, he
hypothesized that events become less memorable since depressed patients appear to use
incomplete encoding strategies to organize the learned information. More importantly,
however, findings suggested that depressed patients were able to benefit and learn when
material was presented in an already organized fashion. One of the main objectives of our
multifactorial training program was to teach older individuals how to use an active
strategy in organizing verbal information. Therefore, it is possible that the mnemonic
training strategies provided an appropriate intervention for mildly depressed individuals in
that they learned to efl‘ectively encode and process learned information that would
maximize the likelihood of subsequent recall. Furthermore, it is likely that these
mnemonic strategies were augmented by relaxation training and educational efl‘orts which

addressed age-related memory concerns.

64

In summary, it appears that minimal levels of depression had no detrimental effect
on objective memory improvement from the pre-test to post-test session. However, it
should be noted that these data are applicable only to individuals with levels of depression

similar to the participants used in the present research.

The Effects of the Multifacton'aj Training Prpgram on Subjective Memorflppaaiaal

Community surveys have indicated that one half of persons over the age of 60
report serious memory problems (Lowenthal et al., 1967). Another study has shown that
more than two-thirds of persons over the age of 75 have expressed concerns about
memory loss. The results of these studies coincide with the finding that reliable
decrements in abstract reasoning and speed of processing have been shown to occur, on
average, during the sixth decade of life (Cunningham, 1987). Furthermore, with the fear
of such insidious diseases as Alzheimer's and other progressive neurological illnesses, it is
not surprising that the integrity of one's memory looms large for the elderly. Surprisingly,
however, previous literature has suggested that there is a marked incongruity between
complaint about memory and actual memory performance. In short, complaints have been
shown to occur with or without an actual deficit in memory (Kahn, Zarit, Hilbert &
Niederehe, 1975). It has been proposed that affective status may be the critical factor
related to this apparent discrepancy between complaint and functioning.

Following this line of thinking, statistical analyses for our third hypothesis
revealed that a significant relationship existed between subjective memory complaint and

depression. This finding parallels previous research in the area (Collins & Abeles, 1996;

65

Derousene et al., 1988;1(ahn et al., 1975; Larrabee & Levin, 1986;1V111iams et al., 1987)
and adds to the clinical lore that emphasizes subjective memory complaints as a diagnostic
indicator for depression.

A major aim of the present study was to examine the effects of a multifactorial
trairning program not only on objective memory improvement, but also on the
improvement of subjective complaints of memory. Considering the prevalence of
subjective memory complaints in the elderly, improvement in this area should become an
important focus for memory training programs. This is especially true since no study to
date has found a reliable positive effect of memory training on subjective memory as
tapped by various metamemory questionnaires. With these findings, the question of
whether the effects of mnemonic training are of sufficient magnitude to warrant the
training effort can be raised. Ifthe elderly do not subjectively perceive positive changes in
their memory after training in mnemonics, of what utility are the measurable changes in
objective memory?

For this study, the fourth hypothesis predicted that depression would play a critical
role in understanding the relationship between mnemonic training and improvement in
subjective memory. In looking at the effects of mnemonic training on subjective memory
appraisal, previous research concluded that depression was not a moderating variable in
the cognitive training-subjective memory relationship (Scogin, Storandt & Lott, 1985;
Verhaeghen, Van Ranst & Marcoen, 1993; Zarit, Cole & Guider, 1981). However, since
there was a general consensus in previous literature indicating that a relationship existed

between subjective memory complaint and depression, our study predicted that depression

66

would play a moderating influence on this relationship. Specifically, since mnemonic
training theoretically provides interventions specific to memory and not to depression, it
was predicted that those with higher levels of depression would not benefit in terms of
subjective memory following the multifactorial training program. Conversely, it was
predicted that those with lower levels of depression would improve in the area of
subjective memory since the training was directly applicable to their memory concerns
and would result in a more favorable subjective appraisal.

An irnitial analysis of our data supported this original hypothesis. That is, group
members who were in the normal range for depression at pre-test significantly improved
from the pre-test to post-test session on the total score of the Memory Assessment Self
Report Scale (MAC-S), which specifically measures subjective memory complaints. This
finding is clinically significant since no published study to date has found a reliable positive
effect of memory training on subjective memory. As Verhaeghen et al. (1992) stated from
the findings of his meta-analysis, "nothing can be inferred about the impact of mnemonic
training on everyday memory performance or on metamemory. " Therefore, our
preliminary findings indicated that mnemonic, relaxation, and educational training was
effective in improving subjective memory in those who were in the normal range for
depression.

However, a post-hoe analyses of the whole sample also indicated that those with
measurable symptoms of depression at pre-test (n = 27) also benefited in terms of
subjective memory improvement. Furthermore, analyses revealed that there was no

sigrnificant difference between the normal depression group and depression group in terms

67

of subjective memory improvement from the pre-test to post-test session. These findings
contradicted our hypothesis that only the "normal depression" group would benefit in
terms of subjective memory. In other words, the whole sample, regardless of depression
level, was found to benefit fi'om the pre-test to post-test session in terms of subjective
memory.

Since statistical analyses revealed that subjective memory complaints were
positively correlated with depression at the pre-test sessiorn, another post-hoc analysis was
conducted to determine whether individuals in our sample benefited in terms of depression
level from the pre-test to post-test session. When the whole sample was examined, it was
found that mean differences for the group were significantly different in terms of overall
depression score. That is, group members sigrnificantly improved in terms of depression
level following the training sessions. In short, this finding may help explain why
individuals improved from the pre-test to post-test session in terms of subjective memory
complaint.

Again, there is a general consensus in the literature that subjective memory
complaints are more of an indicator for depression than for objective memory dysfinnction.
Our study indicates that depression may be a crucial factor in helping to explain our
findings that individuals improve after training in terms of subjective memory complaints.
In essence, the training intervention may need to specifically address the issue of
depression for subjective memory appraisal to improve following the intervention. In the
handful of studies which examined the improvement of subjective memory complaints

following mnemonic intervention, it was found that depression scores remained stable or

68

were not measured from the pre-test to post-test session (Scogin, Storandt & Lott, 1985;
Verhaeghen, Van Ranst & Marcoen, 1993; Zarit, Cole & Guider, 1981). Hence, there
was no reliable, positive effect of memory training on subjective memory. However,
Plotkin, Mintz, and J arvik (1985) found that improvement in depressive symptoms was
significantly related to a decrease in subjective memory complaints following tricyclic
antidepressant therapy and group psychotherapy. Similar reductions in subjective memory
complaints were evidenced between the two modes of intervention. Therefore, it appears
that mnemonic training interventions for the elderly may benefit fi'om directly addressing
the issue of depression during the training sessions.

A limitation of this current study is that we can not specifically state why
individuals improved in the area of subjective memory. Although we can say with some
confidence that subjective memory improvement was concomitant with an improvement in
depression, what was it about our trairning efforts that differed from previous efl‘orts in the
area?

One possible explanation is that our intervention was based on a multifactorial
training approach. Specifically, the intervention consisted of training with mnemonic
interventions, relaxation training, and educational workshops which dealt with common
age-related concerns, including depression. Conversely, for example, Scogin, Storandt,
and Lott's (1985) intervention was a self-taught program of memory skills training which
utilized mnemonic training (i.e., method of loci, face-name mnemonic) and some "basic"
information about memory in later life. Irnportantly, training was self-paced in this study

and done at home by each participant, without group interaction. Our program was done

69

in a group format, which has been shown to affect treatment gains (Verhaeghen et al.,
1992) in terms of objective memory. Furthermore, we placed a strong emphasis on group
discussion across various subject areas. These areas included the topics of memory
awareness and self-evaluation, age—related memory decline, memory and self-concept,
self-change skills, pleasant activities and depression, positive thinking, assertiveness, and
maintaining your memory power (Appendix A). Again, the topic of age-related
depression was a common theme across these subject areas. It may be that this group
discussion format facilitated a more positive self-appraisal for individuals in the group,
resulting in decreased depression levels and improved subjective memory scores.
Furthermore, the inclusion of relaxation training in our intervention may have reduced
anxiety levels, leading to a more positive self-evaluation in terms of depression and
subjective memory.

A second possibility is that the Memory Assessment Self-Report Scale used in this
study better tapped the aspects of metamemory that change with memory training.
Stability of subjective memory complaints (and depression) following training was found
in previous studies fliill et al., 1988; Loonen & Richter, 1988; Rebok & Balcerak, 1989;
Scogin et al., 1985; Zarit, Cole, & Guider, 1981; Zarit, Gallagher, & Kramer, 1981), all of
which used questionnaires other than the MAC-S. As Verhaeghen, Van Ranst, and
Marcoen (1993) stated, changes in metamemory following training may be more subtle
and have more to do with feelings of control, giving participants the feeling that they can
take memory firnctioning "in their own hands." These researchers hypothesized that the

memory functioning questionnaires used in the above studies failed to tap those increased

7O

feeling of adequacy. It may be that the MAC-S does a better job of measuring these
constructs and is more sensitive to those aspects of memory which are addressed with
mnemonic training interventions. Replication studies in the area of improving subjective
memory through mnemonic training with the MAC-S may be indicated to address this
issue of measurement.

A third possibility for the relative success of our training program may have to do
with the relative health of our sample in terms of depression level. Again, our elderly
sample was far below the prevalence and incidence levels for depression that have been
previously reported in epidemiological research. The initial hypothesis that those with
lower levels of depression would improve in the area of subjective memory since the
training was directly applicable to their memory concerns may be accurate in the sense that
our sample was relatively healthy in terms of depression level. If our sample had included
more individuals with severe levels of depression, there may have been differences
between the depression groups. Specifically, it was predicted that those with higher
levels of depression would not benefit in terms of subjective memory following the
multifactorial training program since such trairning does not provide depression-specific
intervention. Therefore, the failure to detect differences between our depression groups
may reflect a sampling bias. Ideally, firture research should examine the effectiveness of a
multifactorial training program in terms of subjective memory with a more severely

depressed subgroup of individuals.

71

Cogm'tive Retraining in the Elderly: Cohort-ReLated Differences in Performan_c_e

In the mnemonic training outcome literature, probably the most frequently
investigated individual difl'erence is age. The typical design includes the contrast of two to
three age groups. Invariably, these studies compare young adults and rrniddle-aged adults
to older adults in terms of objective memory improvement. Not surprisingly, the general
finding of these studies is that older adults improve in terms of objective memory but the
amount of objective memory improvement is less in older subjects than younger adults
(Lachernan & Jelalian, 1984; Lovelace & Marsh, 1985; Rebok & Balcerak, 1989; Rose &
Yesavage, 1983; Yesavage & Rose, 1984). In a meta-analytic review, using
cross-sectional samples, Verhaeghen et a1. (1992) concluded that memory plasticity
decreases monotonically over the adult life span. These researches attributed poorer
performance in the elderly sample to difliculties in the acquisition, retrieval, and
application of the mnemonic strategies.

However, only scant attention in mnemonic training research has been given in
examining the differences between age groups within an elderly sample. A main objective
of this study was to examine whether difl'erences in objective memory improvement would
occur between young/old, moderate/old and old/old age groups following mnemonic
training efl‘orts. A large body of research (Salthouse, 1985; Waugh & Barr, 1980) has
indicated that the old/old (over the age of 75) differ in terms of speed of processing
relative to the young/old (between the ages of 55 and 64). In theory, this slowing of
processing speed may result in the old/old requiring more time to learn the techniques,

and, once they have learned them, more time to implement them during a testing session.

72

Therefore, for this study it was hypothesized that objective memory improvement
would differ between age groups within our elderly sample. Findings did not support this
hypothesis. That is, no significant relationship existed between the three age groups and
pre- to post-test gain on objective measures of memory following the mnemonic,
relaxation, and educational training. In addition, when age was treated as a continuous
variable, findings failed to reveal a significant relationship between age and objective
memory improvement. Therefore, in our sample of older adults, age was not a moderating
factor in objective memory improvement. Again, it is important to note that previous
research has failed to specifically address the issue of objective memory improvement
following mnemonic training within different elderly age groups. However, recent
longitudinal research (Tranel, Benton, & Olson, 1997) indicated that healthy older adults
remained stable in terms of higher order cognitive finnctioning over a 10-year period.
These researchers concluded that mental decline across a broad range of cognitive abilities
should not be viewed as an inevitable correlate of the aging process. Our findings, also
within a healthy sample of older adults, corroborate these conclusions and suggest that
memory remains plastic even in persons in the 8th and 9th decade of life.

One caveat of these findings is that firrther analyses did reveal a modest statistically
significant negative correlation between age and objective memory improvement in the
depressed subgroup of elderly individuals. That is, as age increased within the depressed
subgroup, objective memory improvement significantly decreased. This finding indicates
that older individuals who are depressed may have more dimculty in benefiting fiom

mnemonic training in terms of objective memory performance. In terms of this study and

73

consistent with the speed of processing hypothesis in age-related memory decline, it may
be that age alone does not significantly reduce one's speed of processing, resulting in
measurable objective memory improvement difl‘erences. However, when older
individuals are even mildly depressed, these two factors may act in combination to
produce measurable differences in levels of objective memory improvement. This is
especially true considering that depression has been associated with a shallow encoding of
information and processing speed (Lamberty & Bieliauskas, 1993). Considering these
findings, older elderly individuals who are depressed may benefit from a treatment which
first addresses depression specifically prior to mnemonic training efforts. Our findings
indicated that older individuals can benefit from mnemonic training if depression levels are
in the normal range. However, as age increases even mild levels of depression may affect
objective memory treatment gain.

In addition, a post-hoe analysis of the whole sample was conducted examining the
effects of age on subjective memory improvement. Analyses revealed a statistically
nonsigrnificant relationship between these two variables. That is, individuals in our sample
improved from the pre-test to post-test session in terms of memory complaints and this
improvement was not related to the age of the participants. Again, this investigation is the
first study to date which has shown a reliable, positive effect of cognitive retraining on
subjective memory complaints. Therefore, it is not surprising that no study to date has
shown age to be a moderating variable in terms of subjective memory improvement
following training efforts. Our study indicates that a multifactorial training approach can

be effective, regardless of age, in improving subjective memory.

74

Finally, a post-hoe analysis also revealed that a modest significant negative
relationship existed between age and depression improvement. That is, the amount of
depression improvement was less in older subjects than younger subjects. This finding is
consistent with the previous finding of this study that older individuals who are depressed
benefit less in terms of objective memory improvement. Once again, a practical
consideration in light of this finding is that older elderly individuals who are even mildly
depressed may benefit more by depression-specific treatment (i.e., psychotherapy) or

instead of engaging in mnemonic, relaxation, and educational trairning.

Conclusions and Suggestion for Future Resear_ch

A multifactorial training approach, including mnemonic training, relaxation
trairning, and educational training is an efl‘ective training protocol. It appears that memory
remains plastic even in older age. These results, similar to those of previous studies,
revealed that older individuals benefited in terms of objective memory following the seven
sessions of training. This finding provides further support to the notion that
imagery-based mnemonic and relaxation programs are successful in improving objective
memory in an elderly population. Contrary to previous research in the area of subjective
memory, our training efforts were also effective in improving memory complaints from the
pre-test to post-test session. Furthermore, the improvement in subjective memory appears
to be concomitant with a decrease in depression levels over the course of the training
sessions. It is important to note that these findings directly contradict a recent review in

the area (Verhaeghen, Van Ranst, & Marcoen, 1993), which stated; "It is highly doubtful

75

that these training programs have a beneficial effect on memory fiinctioning, and the
present research shows that a decrease in complaints is not to be expected." (p. 533).

The success of our training program relative to other researched programs may be
attributed to the combination of three factors. First, our program consisted of a
multifactorial training approach which not only utilized mnemonic and relaxation training,
but also placed a strong emphasis on group discussion of age-related memory concerns
(See Appendix A). It may be that this group discussion format in conjunction with
mnemonic and relaxation training facilitated a more positive self-appraisal for individuals
in the group, resulting in decreased depression levels and improved subjective memory
scores. Second, our sample of older adults were relatively healthy in terms of depression
symptomatology. If more severely depressed individuals were included in the group, it is
possible that only those individuals with normal and mild levels of depression would have
benefited in terms of subjective memory complaints and depression. Third, the possibility
exists that the Memory Assessment Self-Report Scale used in this study better tapped the
aspects of subjective memory that change with memory training. Our study appears the
first to use this subjective memory measure in the study of mnemonic training outcome.

Lastly, our study indicates that a multifactorial training approach can be equally
valuable for difl‘erent age groups within an elderly sample in terms of both objective and
subjective memory improvement. However, it was shown that older individuals in the
sample benefited less in terms of objective memory improvement if they evidenced even
mild levels of depression symptomatology at the pre-test session. Therefore, old/old

individuals who evidence measurable levels of depression symptomatology may be advised

76

to seek depression-specific treatment prior to engaging in a multifactorial cognitive
retraining program.

While this study is a preliminary investigation, it has provided us with many
suggestions for firture research.

Ideally, future research should utilize multifactorial training programs similar to the
program in this study and examine outcome in a more severely depressed subgroup of
elderly individuals. There is a consensus in the literature that severe depression is related
to decreases in both memory performance and subjective memory appraisal. Mnemonic
training outcome may be similarly affected by increased levels of depression. The present
sample was far below the prevalence and incidence levels for depression previously
reported in epidemiological research. Therefore, it is clear that the effects of depression
on mnemonic training outcome needs to be more closely examined. In short, elderly
individuals with severe levels of depression may be ill-advised to engage in mnemonic
training if future studies indicate that there is not an improvement across the areas of
objective memory, subjective memory, and depression level. Conversely, these individuals
may be advised to seek depression-specific treatment prior to the multifactorial training
protocol. In this respect, a "streamlining" of treatment approaches for older individuals
with subjective memory complaints could begin to take shape.

A second recommendation for future research is to examine what aspects of this
particular training protocol resulted in objective memory improvement, subjective memory
improvement, and reduced levels of depression symptomatology. Again, it is noteworthy

that the type of multifactorial approach used in this study has less often been the focus of

77

research, with more studies examining the implementation of a single program (i.e.,
method of loci or face-name mnemonic or relaxation training). This study appears the first
to find a reliable, positive effect of mnemonic training on both subjective memory
complaints and depression. Therefore, this type of approach is indicated for older
individuals with minimal levels of depression. However, a limitation of this current study
is that we can not identify why individuals improved across the three areas of concern.
Future research needs to tease out the effects of mnemonic training (i.e., method of loci,
face-name mnemonic), relaxation training, attention/concentration training, and the type of
educational group training which was implemented for this study. Furthermore, firture
research should examine whether older adults maintain these memory and depression gains
over time, and if so, for how long. Such research work might lead to a more eflicient and
cost-effective treatment protocol for subjective memory complaints. Such an effort is
certainly warranted considering that community surveys have indicated that one half of
persons over the age of 60 report serious memory problems (Lowenthal et al., 1967).

This study also lent credence to the belief that subjective memory complaints may
be associated with depression. However, much more research needs to be done in the
area. This is true since subjective memory complaint may also be an early symptom of a
degenerative disorder such as Alzheimer's disease. Information relating the accuracy of
these complaints and how they specifically involve different aspects of depression could
aid health care workers in formulating more accurate diagnoses. Future studies should
carefully assess this relationship to help clear up the diagnostic picture. If this were

accomplished, people's self-reports of memory could actually help serve in describing the

78

nature of the disorder and help with future treatment planning. Specifically, those found
to have subjective memory complaints which were unrelated to a dementing disorder
could be referred to a training program such as the one utilized for this study. Such an
approach would be invaluable for the mental health of our elderly since subjective memory
complaints are especially common in this population and since the incidence and
prevalence of actual progressive memory disorders is relatively low.

However, in order to study the validity of subjective memory complaints, more
research needs to be conducted in the measurement of subjective memory. It is possible
that the Memory Assessment Self-Report Scale used in this study better tapped the
aspects of metamemory that change with memory training. As Verhaeghen, Van Ranst,
and Marcoen (1993) stated, changes in metamemory following training may be more
subtle and have more to do with feelings of control, giving participants the feeling that
they can take memory functioning "in their own hands." It may be that the MAC-S does a
better job of measuring these constructs and is more sensitive to those aspects of memory
which are addressed with mnemonic training interventions. Future research needs to
address this issue. In addition, efforts into the construction of additional subjective
memory measures should be considered. Specifically, such measures should allow for the
adequate discrimination of the frequency, type, quality, and degree of memory difficulties.
Ifthe memory questionnaire is too general or only examines the fiequency of memory
problems, such as many existing questionnaires, potential interrelationships with memory

recall and depression may be masked.

79

Finally, as outlined in this study, outcome findings following intervention vary
widely. Little is known about the predictors of response to training. The present findings
suggest that a mutifactorial approach may be helpfinl. Furthermore, it is hOped that the
issue of depression will be more closely evaluated in studies following this research.
However, other important variables to consider are the effectiveness of these techniques
across different socio-econorrnic and cultural groups. This study, as well as the majority of
reviewed studies, have explored the effectiveness of training with white middle-class
samples. Therefore, a number of potential sampling biases may limit the generalizability of
these results. In short, we know little about the effectiveness of these techniques in
Afiican-Arnerican, Hispanic, Asian populations etc., nor do we know if the memory
complaints are similar across socioeconomic and cultural strata. It is highly recommended

that future research address such issues.

APPENDIX A

APPENDIX A

Educational Handout #1: Memory Awareness and Evaluation

Most of us are not aware of how we use our memory and e usually don't realize
the mental effort we are expending. We aren't aware of the methods we use to remember,
nor do we know why we forget.
Choosing what to remember
1. You can't remember everything; it's just not humanely possible. Thus, the first step in
maximizing your memory power is to make choices about what to remember.
2. You must recognize and apply mental effort when it is needed. Assuming that you'll
remember what is important is not enough to guarantee remembering.
3. Be aware of your memory choices and make sure they are the best ones for you. In
this way, you focus your attention on retaining some information and disregarding other
things. By applying your effort and mental energy selectively, you give yourself a greater
chance of memory success.
4. Maximize your strengths by taking on tasks that are related to a subject with which you
have some familiarity and that can be approached with memory methods that word well
for you. Also, take into account the time you have available for memorizing. As you
become more experienced with a variety of memory strategies, you will gain confidence in

tackling unfamiliar material.

80

81

5. Choosing to forget things that are not important or necessary to you (for example,
movie plots, details of a book) can maximize your memory power.
6. Shared memory systems are those that develop between people who live with each
other, such as a husband and wife. In such a system, the memory requirements of their
shared lives are divided up, with each providing cues (cues are like a hint) and reminders
for the other. For example, one spouse may take on all responsibility for maintaining the
family cars while the other may be responsible for paying all the household bills.
Choosing how to remember

Awareness is critical. You need to be aware of the memory techniques you can
choose fiom and the reasons for choosing one over the another. Without this awareness,
you will probably unconsciously use a well-practiced but perhaps inappropriate strategy
from you repertoire. For example, you may be a Visualizer who typically remembers by
using mental pictures. This technique will not word best for some information you must
remember.
1. Be aware of your memory strategy options. As you learn more about the different
strategies available, you will be able to choose the best ones for the memory activities you
need to do.
2. External memory strategies, such as writing notes or using calendars, can expand your
memory power since their correct application requires thinking.
3. Make the strategy fit the task. As you probably already know, a datebook or calendar
is the most practical way to recall appointments. In such cases, other memory strategies,

such as visualization, are not as effective.

82

4. Combining internal strategies, such as repetition or verbal elaboration, with external
strategies, ofl‘ers the greatest memory power possible. This technique not only maintains
your internal memory skills through regular use but also prevents the overload of internal
memory. We will learn more about the different types of internal and external memory
strategies in future sessions.
SW

Most people use very few strategies and are basically quite happy being unaware
of how they use them. However, becoming aware of what you do to remember is an
important first step if you want to improve your memory. You can increase your memory
power most effectively by identifying and building on your existing memory strengths.
The following memory tasks should help identify the strategies you are already using:

1. Commit new information to memory

2. Remember and complete some errands or activities

3. Remember habitual routines

4. Remember past events

There are a number of strategies useful in accomplishing these memory tasks. To
commit new information to memory, you may read the material aloud again and again, or
create lists which group what you are trying to remember into similar categories. To
remember to do something, you may make lists and post them in a regular place, or
visualize yourself doing the errand. Remember habitual routines, such as locking the door
when you leave, may be accomplished by asking yourself "Did I lock the door?" Recalling

past events may be done with photo albums or old letters. You may already be using

83

these, or other memory strategies. Some memory strategies may be new to you however.
During this course, we will introduce you to a variety of memory strategies and have you

practice them.

84

Educational Handout #2: What Happens to Your Memory as You Get Older?

1. Your thinking gets slower as you get older. It will take longer to solve problems and
to get something out of your memory. You will especially notice this when you must
solve a problem right away and can't take the time to really think about it. It is also very
evident when you are doing something very diflicult or that you have never done before.
One way around this is that the more familiar you are with a task, such as sewing, the less
you will slow down as you get older. So one thing that you can do is try to keep up with
the things that interest you. The more you do them, the less you will slow down as you
get older.

2. You use memory strategies less often as you get older. You may use them less often
because your thinking is getting slower or because the information is told to you too fast
to think of a memory strategy. Also, you may just get out of practice from not using them
a lot because you have never learned memory strategies in the first place. This last reason
is very common. Many people only learned information in school by rote. This is where
you go over the information again and again till you remember it. Even if you haven't
used memory strategies before though, don't worry. You can still learn them and they can
increase your memory ability by half!

3. It becomes harder to pay attention as you get older. You may have found that it is
easier to become distracted by noise and people around you. This is especially true if you
have to wear a hearing aid. At a get-together, it is much harder to follow more than one

conversation at the dinner table at the same time. This is also the reason for misplacing

85

your keys and glasses. During this course, we will also teach you ways to improve your
attention and concentration.

4. Learning something takes longer as you get older, so don't be anxious if it takes more
time to learn something than you think it should. It just takes longer, it doesn't mean you
can't learn it. Give yourself the extra time to learn something, try to enjoy what you are
learning, use memory strategies, and practice, practice, practice!

5. You need more cues as you get older to remember something. Remember, cues are
like a hint. They help you remember something. For example, your daughter may help
you remember where a snapshot was taken by cues. She may say, "Remember mother?
This picture was taken at grandma's house. It was cousin Jack's birthday. It was really
hot and we all went swimming." Here, the daughter is using her grandma's house, the
birthday, the heat, and the swimming as cues, to help the mother remember when the
picture was taken. The more of there hints you have, the easier it is to remember

something.

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Educational Handout #3: Memory and Self Concept

1. The negative stereotypes regarding aging are one of the primary reasons that
nniddle-aged and older people have low self-confidence about their memory abilities. Just
look at TV shows. The female bailiff that used to be on Night Court always made
negative comments about herself that were related to age. What you should really see is
that she was a very good actress who learned her lines every week just as well as the
younger actors and actresses.

2. These portrayals of what happens with old age are changing. Have you seen that
advertisement with the older people out motorcycle riding in their red leather clothes?
The phrase, "I‘m not getting older, I'm getting better," is heard a lot more often now.

3. Even if you don't believe this negative view, it can still influence your thinking since it
is all around you. For example, you may begin to put yourself in the shoes of those you
see on TV and begin to feel what they are feeling. Slowly, it can change the way you
think.

4. Other older individuals actually accept the myth of severe memory decline, as much as,
or more so, than younger people do. Part of it may be due to when you were young.
Then it was commornly believed that senility was inevitable and everyone would eventually
be afflicted with it. Although we now know this isn't true, it is hard to throw off the years
or false beliefs, especially if you learned them when you were young.

5. Have you ever noticed that when memory failures occur, the reason other people give

for the person's problems seems to depend on how old the person with the problem is.

87

For example, if the person is older, the problems are due to the age of the person. Ifit is a
younger person with some problems, it is due to memory overload.

6. If you believe in this negative stereotype, even unconsciously, you have set up a barrier
for yourself. The barrier is a low memory self-concept. which mean that you don't have
confidence in your memory ability. This lack of confidence can prevent you from
maintaining or improving your memory.

A lack of self-confidence hurts you memory ability in four ways:

1. It increases your anxiety and/or depression about memory losses, even if these losses
are only imagined. People who have a low self-concept about their memory sometimes
worry so much about their ability that they become anxious or depressed. Even though
these are normal feelings when one is confronted with a real loss, it will decrease your
memory abilities when you worry non-stop over memory losses that may never occur.
Such a fear is common in those with a negative belief about what happens with aging.
Anxiety interferes with effectiveness remembering. So, if you are nervous that you might
forget something, there is a good chance that you will forget it. This can happen at any
age. Do you remember taking tests when you were back in school? Ifyou were really
nervous about a certain test, chances are you didn't do as well as you could have.

2. It lead you to use an unrealistic yardstick to evaluate your own abilities. Your
self-concept can also get worse if you make unrealistic demands on yourself. Remember,
you are expecting too much of yourself if you don't take extra time to study something
you want to learn. You are being unrealistic if you think you will be able to concentrate

on reading with the TV set blaring in the next room. When you cannot learn as quickly as

88

you used to, and cannot concentrate as well, you need to recognize that you may be
experiencing normal age-related changes, instead of thinking that your mind or your
memory is deteriorating.

The worst thing about a low self-concept is that it all leads you to emphasize your
failures. You are likely to jump on every small memory mistake as "proof" of your failing
rrnind. You "forget" that your memory never did function perfectly all the time. With a
negative self-concept, you fail to notice the number of successes you have every day. If
you notice every failure and none of your successes, your self-confidence will dwindle to
nothing.

3. It results in reduced memory effort. Lowered self-confidence, even if it is not based
on the truth, can lead you to act in ways that weaken your existing memory skills. You
may give up too easily on a memory task. You may not ask anyone for help because you
are certain you cannot improve. You may not try new memory strategies because you
presume that the effort will be wasted. This type of behavior is self-defeating and will help
cause your memory to actually get worse. When you give up in the face of new situations
that require memory effort, your failure firrther reduces your self-concept. You will
believe even more strongly that you won't succeed, no matter what you do.

4. It discourages you from seeking intellectual stimulation. When you have a low self-
concept about your memory ability, you are very likely to create a world around you that
does not require you to think very much. You may not take on intellectual challenges
because you have a fear that you will fail. Because myths about aging are so widely

accepted, you may find, as you get older that people around you suggest that you retreat

89

fiom diflicult tasks. They may recommend a narrowing of life's challenges, even though
challenge is how we continue to thrive. In a well-meaning way, they will ofl‘er to do
things for you. When you leave an environment that requires you to use your memory
abilities, it is very easy to sit back and relax because others will not place high memory
demands on you. However, by not challenging your mind, you may no longer be able to
meet a challenge when one comes. A low self-concept can lead to a reduction in
intellectual stimulation because you don't seek it out and this in turn will end up causing
memory difliculties since you are not using your memory. Think of your memory as a
muscle that must retain flexibility and strength. Without regular exercise, it won't work

well for you when you need it. Remember resting is rusting!

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Educational Handout #4: Self-Change Skills

Everyone has certain behaviors that they wish they did more or less often. Usually
when we don‘t behave how we like or as consistently as we like, we end up feeling
miserable. The skill of self-control can be used to tackle these problems. Unlike will
power, self-control is a skill that you can learn in order to make changes in your life. To
be successfinl, self-change requires that 1.) you believe that you can change, 2.) you
recognize self-change is a skill that can be learned, and 3.) you develop a plan of action.
There are 6 steps for making a self-change plan of action:

1. Pinpoint the behavior that you want to change. It may be a desirable behavior that you
want to do more consistently or a negative behavior that you want to do less often.

2. Find out where you are at. How often do you do this behavior and in what situations
do you do it? You need to know this in order to set reasonable goals for yourself.

3. Look for any people and situations that make you more likely to perform or not to
perform this behavior. Ifit is a behavior you are trying to avoid, avoiding people or
situations associated with that behavior will make the problem behavior less likely to occur
in the finture.

Ifit is a behavior that you want to increase, being with people or situations that are
associated with that desired behavior can lead to greater consistency in the behaviors
expression. For example, if you want to get fit by taking a long walk every day, do it with
other people who also want to take long walks. Each of the "group members" can help

motivate the other members to take walks regularly. In addition to being more consistent

91

with this behavior, it will now be a finn activity rather than just anther task to be
completed. This will lead to practicing your desired behavior more consistently.

4. Look for the consequences of the behavior you want to change. How do you feel
about yourself and how do others feel about you when you do this behavior? Ifyou want
to decrease a behavior you don't want it to be followed by a positive experience that will
make you more likely to do that behavior in the finture.

However, if you have a behavior you desire to do more often, receiving positive
support from yourself and others when you do this behavior will make you more likely to
do that behavior in the future.

5. Set a goal for yourself. How often do you want to do this behavior per day or week?

Do you want to do this behavior more or less often in certain situations or around certain
people? Use these questions to set reasonable and specific goals for yourself.

6. Reward yourself when you accomplish your goals but not when you fall short of them.

Also, make sure you choose a reward that is meaningful to you.

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Handout #5: Pleasant Activities and Depression
1. The number of pleasant activities that you engage in is related to your mood. Such
activities can be divided into 3 areas:

1a. Pleasant Social Interactions: These are interactions with others that feel
positive and pleasurable. For example, when you have a nice conversation with fiiends.

lb. Competency Experiences: These are experiences that make us feel skilled or
competent. For example, when you do something well.

1c. Incompatible Responses: These are activities that are incompatible with
feeling depressed. For example, when you laugh or when you sleep well.
2. If the number of pleasant activities falls below a certain level, your mood is likely to
become more depressed.
3. It is important to have a balance between neutral or unpleasant activities and pleasant
activities. Ifyou do keep a balance, this can keep your memory fimctioning better because
your mood will be better.
4. Some problems you may have in carrying out a Pleasant Activities Plan are:

Problem #1 : You may have to do some unpleasant tasks that need to be done but
end up going over into the time you have scheduled for a pleasant activity.

Solution #1: Use time management. Plan tasks so they are started soon enough so
they do not run into your time for pleasant activities.

Problem #2: Someone you do the activity with moves away.

Solution #2: Work on finding another pleasant activity to do.

93

Problem #3: You become filled with anxiety and discomfort when you do a
pleasant activity.

Solution #3: Find out why you are tense or nervous and fix it.

94

Educational Handout #6: Positive Thinking

A. Some thoughts on positive thinking:

1. Your thoughts can influence your mood.

 

2. Thoughts seem like they are automatic but they are under your control. You must
learn to become aware of your thoughts and take them seriously.
3. If you have a tendency to have negative thoughts about yourself, this can cause you to
become depressed. Ifyou become depressed, your memory will also suffer.
4. How you think about yourself and how you feel are related. Sometimes how you think
causes you to feel a certain way.
You can use your thoughts to help you, however. For example:
1. Your thoughts can be used to turn your dreams into real-life goals.
2. Your thoughts can help you to pay attention better.
3. You can use your thoughts to make your memory better.
4. You can use your thoughts to help you see problems ahead of time. This can give you
time to think of a solution.
5. Your thoughts can keep you calm and on track with your life.
6. Your thoughts can help "get you going;" that is, they can motivate you to do
something.
How to Reduce Negative Thoughts:
1. Stop those negative thoughts:
1a. Yell "STOP" when you have a negative thought. Then say it to yourself in

your head a few times.

95

1b. Say "I am not going to say that now" when you have a negative thought.
Then say it to yourself in your head a few times.

1c. Wear a rubber band on your wrist and snap it whenever you think a negative
thought.
2. Set aside a time to worry: If you need to think about certain negative thoughts, then
schedule a time to do so for no more than 30 minutes per day. Only allow yourself to
have negative thoughts during that time.
3. Exaggerate: Make your negative thoughts look foolish. For example, exaggerate how
bad the problem you are having negative thoughts is.
C. How to increase your positive thoughts:
1. Notecards: Carry 3x5 cards with positive statements about yourself on them. For
example, "I am quite good at..."
2. Habits: Develop the habit of thinking positive thoughts when you do certain behaviors.
The best behaviors to use are those that occur frequently. For examme, say positive
thoughts as you brush your teeth or clean the dishes.
3. Notice what you accomplish: Notice what you accomplish rather than what you do not
accomplish by making a list of daily successes. For example, getting to an appointment on
time.
4. Give yourself rewards: Reward yourself for positive thoughts. For example, when you

think, "I did a good job on that," give yourself an item you enjoy.

96

5. Think of any easier times to come: Think of a time in the near-fixture when things will
be easier for you. It is OK. to feel down. Feeling down gets bad when you lose all hope.
This will lead you to feeling depressed and it will cause your memory to get worse.

D. Guidelines for Positive Thinki_ng

1. Pay attention to the situations where you seem to have negative thoughts.

2. See if there are any good things you get for having negative thoughts, especially
around others. For example, are people nicer to you?

3. Do you punish yourself for thinking positive thoughts? Do you think of yourself as
self-centered or conceited for thinking positive thoughts about yourself?

4. Keep track of words that lead to negative thoughts such as "I should have...I
must...This is awful...This is terrible...I will never."

5. Use words that can lead to positive talk such as "I wish" or "I would have preferred"
When you have negative thoughts, you can also:

1. Prove to yourself how those thoughts don't make any sense. Give yourself examples of
how those negative thoughts are incorrect.

2. Replace "should" and "on t" thoughts with "Why should I?"

3. Change words like "terrible" and "awful" to "I would have liked to..., but is it really
terrible?"

4. Change words like "I will always be like this" with words like, "Just because this time it

happened..., does it really mean always?"

97

Educational Handout #7: Assertiveness

Assertiveness gives you the ability to express your thoughts and feelings openly:

1. It can help develop close, warm relationships with others.

2. It can prevent an unpleasant encounter.

3. It can give you the means for obtaining more positive responses from others.
4. It allows other people to understand you better.

These can all keep you from becoming depressed. This is important since
depression can affect your memory. When you become depressed, it is harder to
remember most things. Only sad things are remembered easier. As a matter of fact, that is
about all you can remember. This in turn will make you even more depressed and your
memory even worse.
lbw to becom_e_assertive:

1. Develop a personal problem list of 5 problems that meet the following criteria:

1a. A situation that you are currently handling in a non-assertive way.

1b. A situation that occurs regularly in your life.

1c. A situation that is troubling you.

1d. A situation that is not too specific or general.

2. Monitor your assertiveness:

Track your amount of assertiveness and level of comfort in your problem situation.
Use a scale fiom 0 to 5. For assertiveness, 0 means you were not assertive at all and 5
means you were very assertive. For comfort, 0 means you feel unpleasant and 5 means

you feel very comfortable with how you handled the situation.

98

3. Practice assertive imagery:

3a. The goal is to handle situations as well as you can and to feel good about how
you handled them.

3b. Start with easy situations

3c. Transfer from imagery to real life once you are comfortable with how you

handled it in your mind.

99

Educational Handout #8: Maintaining Your Memory Power

The following points are important to consider if you want to get the most out of
the course and really improve your memory power.
1. Just reading these handouts about memory won't cause your memory to improve. It's
like reading an exercise book. Your body won't get in shape, no matter how good the
book is, without doing the exercises.
2. Also, a one day memory workout will not permanently improve your memory either. It
is just like a crash diet. Just as you gain back the weight because you haven't changes
your eating habits, so will you also fall back on your old memory techniques, even though
they may not be as good.
3. Only deliberate and regular practice of these techniques will lead to memory
improvement. To change your memory permanently, you must make these strategies a
routine part of your everyday life.
4. When you become skilled in the use of these strategies, they will become a natural part
of your daily interaction with the world. You won't have to devote any conscious mental
energy to figure out how to apply a strategy. You will be able to use these strategies
automatically without giving them any thought. Remember, well-learned strategies are
not likely to be forgotten as you get older.
The best way to practice the memory strategies that we showing you is to:
1. Pick a strategy that you are interested in or one that you would like to be able to do

better.

 

100

2. Use it for simple memory tasks. For example, to do 3 errands, or to remember 2
names, or to remember a news item you want to talk about.

3. Keep a list as a back-up strategy in case you forget. Do this especially when you are
trying to remember something very important.

4. Practice regularly.

5. Keep practicing the memory strategy until you feel confident in using it. Then try the
memory strategy on harder tasks.

6. Use this method to practice other memory strategies.

Different ways to practice are:

1. Use a different strategy for each type of task. For example, use one type of memory
strategy to learn the names of people in your building and another one for remembering
your errands.

2. Use one type of memory strategy all day, no matter what the task. For example, you
can use the same memory strategy to do errands, to buy groceries, to take your medicine,
and so on. At the end of the day, look over your successes and failures.

3. Make an effort to remember 5 to 8 things each day.

4. Use simple memory strategies for simple tasks and complex strategies for harder tasks.

APPENDIX B

APPENDIX B

The Beck Depression Inventory

 

 

 

T31
- I - Date:
Name: Marital Status: __ Age: __ Sex:
Occupation: Education:

 

 

This questionnaire consists of 21 groups of statements. After reading each group of statements carefully.
circle the number (0. 1. 2 or 3) next to the one statement in each group which best describes the way you
have been feeling the past week. including today. If several statements within a. group seem to apply equally
well. circle each one. Be sure to read all the statements in each group before maflnL your choice.

 

 

 

 

 

1 ° I do not feel sad. I ° I don't feel I am snyworse than
, I feel sad. anybody else.
3 I am and all the time and I can't snap out. of it. i 3%“?! myself for my weaknesses
3 Iamsosadorunhappythatlcantstandrt. , Iblamemyselfsllthetimeformyfsults.
. 3 I blame m If for everything bed
1 ° Iam not particularly discouraged about. the that b.9935:
uture.
; I feel discouraged aboult ttlnfffuture. 9 0 I don't have any thoughts of killing myself.
IfeelIhavenothmgto 0° 0 ‘0‘ I Ihsvethoughtsofln'llingmyself.but1
3 I feel that. the future is hopeless and that. would not carry them out.
‘mmpammnmmmWL a rwmmnmamwmmmmr
, .
3 o Idonotfeellikeafailure. IwouldlallmyselfifIhadthechsnce.
‘ ‘ ed than th
ifiméfl. more 8 111 0 I don't cry any more than usual.
’ AsIlookbackonmylife.allIcanseeis ‘ Icrymorencwthanlusedto.
a lot. of failures. 3 Icryallthe timenow.
' IreeII amaoomplete failureas aperson- a I usedtobesbletocry. but nowIcsn'tcry
even though I want to.
4 ° Igetasmuch satisfactionout of thingsasI
usedto. 11 ° Ismnomoreirritatednowthsnleversm.
‘ I don't. enjoy things the way I used ‘50- I I get annoyed or imitated more easily than
' I don't get real satisfaction out of anything I used to.
anymore. . _ 3 I feel irritated all the time now.
" I am dissatisfied or bored With everything. a I don't get irritated at. all by the things that
used to irritate me.
5 ° I don‘t feel particularly guilty.
‘ Ifeel suiltyasood Pm“ the time- 12 o Ihsve not lost interestinother people.
' I feel quite 81-15-113? most 0‘ the time. I I am less interested in other people than
3 Ifeel guiltyallof the time. . 1118de be-
8 I have lost most of my interest in
° I don't. feel I am being punished. a other people. 1
, I feel I may be punished. I have lost all of my interest in other poop e.
' Iexpecttobepunished. ‘3 o I d . io be 11
. . make ecrs ns a ut as we as
3 I feel I am bemg punished. I ever could.
, 1 1 . . 11
7 ° I don’t. feel disappointed in myself. i 32:32, decisions more
‘ I am disappointed in myself. 2 I have greater difficulty in making
3 I am disgusted with myself. decisions than before.
3 I hate myself, 3 I can't make decisions at all anymore.
Subtotal Page _1 . CONTINUED ON BACK

 

 

 

101

102

 

 

 

I4

18

I7

18

Gut-O

”Di-'0

 

I don't feel I look any worse than I used to. 19 I haven‘t lost much weight. if any. lately.
I am worried that I am looking old or I have lost more than 5 pounds.
unattractive. I have lost more than 10 pounds.

I feel that there are permanent changes I have lost more than 15 pounds

in my appearance that make me look '

unattractive.

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

I can work about as well as before. 2“ . d

It takes an extra effort to get started at {haggfsm wome about my health

doing something. éd bo h . al bl

I haveoto push myself very hard to do gmgghesaangwggr upprget ems

“We. stomach; or constipation.

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

I am so worried about m physical

I can sleep as well as usual. problems that I cannot tiltik about

I don't sleep as well as I used to. anything else.

I wake up 1 -2 hours earlier than usual

and find It hard to get back to sleep.

I wake up several hours earlier than I 21 I have not noticed any recent change

used to and cannot get back to sleep.

I don't get more tired than usual.

I get tired more easily than I used to.

I get tired from doing almost anything.
I am too tired to do anything.

My appetite is no worse than usual.

My appetite is not as good as it used to be.
My appetite is much worse now.

I have no appetite at all anymore.

 

in my interest in sex.

I am less interested in sex than I used
to be.

I am much less interested in sex now.
I have lost interest in sex completely.

 

 

 

Subtotal Page 2

Subtotal Page 1

 

 

 

__ 'Ibtal Score

 

TF’C 0528-002 22 23 24 25 26 27 28 29 30 B C D E

c‘

APPENDIX C

APPENDIX C

The Memory Assessment Clinic Self Report Scale

Memory Assessment Ciinicc. Inc.

Sell-Ra tings ccle

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exec: SittEIZCf‘. cescn’cec. In 5:53 ccscs :zezsa gzve yccr .mc .s::.cr-. :e’ zen-~91 1:;

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wcclc rememcer.

 

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lca. mes-.07. 33 cc. .carec :: Ctner :ec::e. Fiesta use :r.e five-:33:
sccle a: the age: :c rec 3:: Ice! a: .ver.

 

 

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103

104

 

-
d

How would you describe your ability to remember the following?

 

 

" Meanings of woros met you use only rarely
1:. Telephone numcers or :2"; ooces that you use on a monthly basis or [1] [2} El [4; [:1

less often

 

 

 

 

 

 

 

Details of lamiiy events the: occurrec ounng :r. :as: year

 

 

 

 

 

 

 

 

 

14.
15. high door you entered when snocoing in a large decanmen: store [11 [2} (SI [4. [53
or mall
16. To take along. when leaving the home or office. any items mat you [71 (2! (31 [4: [5;
intended to ran (for instance. an umbrella or a laser to mail)
17. How to reach a geogracnio location you have visited once or :wice [11 [4} [5! f" [53
M l’” (3.7 l-‘-' [51

18. Meanings cl wcros you once knew very well

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

is. wna: you read in the newsoaoer one coy ago
20. Who was with you a: events attencec wear: or monms ago. [71 [2: [31 [4 [El
21. Where you have out ocjeots (soon as keys; in the home or office [11 [2} [Si [4: 5':

m (2: [:1 l [43 l (53

 

 

 

 

”I In general. as ccmoareo to the average inoivicual. how woulo you
ces rice your memory?

 

In this :sr‘. of :3 form a numoer or everyosy memory croclems that
oeoole reocrt are oescrfoec am: in escn case you are askeo :o Enclose
how often you exoerzencs me :roclem. As .n For: :. :lessa carefully man
the box that hes: ces noes your resccnse.

 

 

 

 

 

 

 

 

l-Iow otter: would you say that you do each of the lollowing?

23. Go into a room to get somemxng anc lorge: wnaz you are after [1i [2: [3} [43 (E?

24. Forget to :rxng us an imoortan: :cin: you nao intencec :o menzlon [13 (2: (31 (4; [5]
ounng a conversation

25. Forge: ma: you fch someone someznmg anc :eel :na: :erscn the [1} Z; [3; [-‘3 [5;
same thing again

2‘3. Have difficulty recalling a wcr: you wist‘. to use [7} [2} [3l [41 (Si

2‘ Have :o ::co and mink wner: o5s:inguisning ngn: from lei: [ll [2} (3; (:3 [53

25. Forge: an entire event. such as attendin a car? or navin a visitor 7' 2' 3' .I 5

l S l l l l

29 Miss the coin: someone else is making swim; a conversation (11 [2: [31 (4; [5]

EC. Feel matawcro crname you wan: :o rememoeris "on the tin olyour [ii [2! [3i (4! [Si
tongue" but cannot he recalls:

3‘. Forge! me name of J 93m'“-‘-" C3495? “I [2: [:1 “I [5;

L

 

105

How olten would you say that you do each at the loilcwing?

46.

Call someone you recently met by the wrong name

Fail to rep-temper a name or worc when trying b”: ’93:” it later
Dial a numoer anc‘ .‘or;et wncm you were calling 'oelore 3‘5 33C“ is
answered

n’ ...-O {3 Van] {mgcnant CC YCU

we uics

Forget an appointment or other eve

Take a surprisingly long time to recall a fact :h tycu know quite well
(and co eventually rememoer)

Have difficulty following a conversation when there are cistractz'cns
in the environment Such as noise from a T! or a racfo

Forget wnion waiter took your orcer in a restaurant

Have to re—reec earlier paragraons from newscaoer or magazine
Story to unoerstanc the point

Fess the point wnere you intenoec to exit wniie crzving a car or
taxing public transportation

Fail to r cognize people wnc recognize you

Have trcu‘ole linoing your piece again when interruptec in reacing

Arrive at the grocery store or pharmacy anc .‘orget wnat you
intencec‘. to buy

Meet people who seem .‘ammar out o: .‘t remem'oer where you me:

thern

Confuse one were with another when they souno the :am

Store an important item in a place wnere it will be safe she then
forget where it is

Please use the live point scale at the right to answer the tcllowing

question.

47'.

How would you descri'ce your memory, on the wnole. as compares:

to the test it has ever been?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

106

Please use the the point scale at the right to answer the lollowing
question.

43. Compared to the best your memory has ever been. how would you
describe the speed with which you now remember things?

Please use the five point scale at the right to answer this final question.

49. l-Iow much concern or cistr :3 do you teel about your memory at
this time?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

107

 

 

 

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APPENDIX D

 

APPENDIX D

The California Verbal Learning Test

LIST A: Immediate Free Recall. Trials 1- 3
Instructions to Examm

Trial 1:

Let 's suppose you were going shopping on Monday. I '11: going to read a
list 0! items for you to buy. Listen carefully, and when I '11: through, I
want you to say back as many of the items asyou can. It doesn 't matter
what orderyou say them in —just tell me as manyasyou can. Areyou
ready?

Trial 2:

I'm going to repeat Monday‘s shopping list. Again I want you to stay
back as many items as you can. in any order. Be sure to also say the
items on the list thatyou told me the first time.

Trials 3-5:

 

I'm going to repeat Monday's shopping list. Again. I want you to say
back as many items as you can in any order. including items you may
have already told me.

 

 

KEY FOR CODING
RESPONSE TYPE

C = Correct
P s Perseveration
I = Intrusion

 

 

 

 

Trial 2
Responses

Sumntlo Clix-tel-
Hemline Cluster

17!-
WP.

Sam-Mb Clueur

E

 

108

109

LIST A: Immediate Free Recall,
Trials 4 8:. 5

Table of
Free-Recall
Word Order

'h-ial 5
Responses

Sam-nth: C'nIIOI

I-
I
..
I
2
U
3
..
z
u
E
0
m

LIST A

Short Delay

List

   

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Serial cluster I I I I I I I
score:
Summary Table: LIST A (Monday List) Table of Serial Position Recall:
Immediate Free Recall LIST A Immediate Free Recall.
Pei-savor I Semantic hie-ls 1'5
TRIAL Cornet (C) anon: (P) lntrumonl (l) Clusll'r Numbar Percent
I eron Corn-ct of Tbtnl
l l
I P
nmncy
2 i
I
Mmdlo
3 — _
Rauncy
d —_ _
max. 100".
5 ____ —
mom. I
W

Record these totals in the
Summary Table 0! Recall Errors (p 9)

110

LIST B
(Tuesday List)

Instructions: Now let's suppose that you
planned to go shopping again on Tuesday.
I'm going to read a new list of items foryou
to buy. When I'm through, I want you to say
back as many asyou can. in any order.

 

Responses

Recall Order

    

 

 

E
3
5
E
5

 

LIST A:
Short-Delay Free Recall
Instructions: Now I 'd like you to tell me

all 0! the shopping items you can from the
Monday list.

Samantha Cluster

TYP-

 

Correct (C):
Perseverations (P):
Intrusions (I):
Semantic cluster score:

Serial cluster score:

 

 

Correct (C):
Perseverations (P):
Intrusions (I):

Semantic cluster score:

 

 

 

 

 

111

LIST A:

Short-Delay Cued Recall

Instructions: 7131! me all of the shopping
items from the Monday list that are:

(category)

Responses

Spices & Herbs:

Tools:

 

Fruits:

Clothing:

 

Correct (C):
Perseverations (P):

Intrusions (I):

 

 

 

Time of day Short-Delay
Cued Recall completed:

Responses

 

112

LIST A:
Long-Delay Free Recall

Time of day Long-Delay Free
Recall begun:

Time of day Short-Delay Cued
Recall completed:

I-
0
.-
U
2
U
2
5
o-
B
9
3!

Total delay:

(Note The total delay should be about 20 minutes.)

Instructions: I read some shopping items
toyou earlier. I'd like you to tell me all the
itemsyou can from the Monday list—that was
the first list. the one that Iread to you five
times. Go ahead.

 

 

Correct (C):
Perseverations (P):
Intrusions (I):

Semantic cluster score:

 

 

 

113

LIST A:
Long-Delay Cued Recall

Instructions: Tbll me all of the shopping
items from the Monday list that are:

 

 

 

 

 

 

 

 

 

 

(category)
Clothing: 1700151
Fruits: Spices & Herbs:
Correct (C):
Perseverations (P):
Intrusions (I):
Summary Table of Recall Errors
List A. I a
Tr. 1-5 I Short-Delay Recall : Long—Delay Recall
Error Type Total List B I Free Cued c Free I Cued Total
Perseverations I
Intrusions: Free Recall I

 

 

 

 

 

Cued Recall

 

 

 

 

114

IST A:
Long-Delay Recognition

FALSE POSITIVES

Instructions: I'm going to read a list of
shoppingitems. After I read each 1' tem. say
"Yes"i! the item was from the Monday list.
and say “No" int was not.

(Note: For each “Yes" response. place

a (w) in the one blank space to the right
of the word: for each "No" response. leave
the space blank.)

 

A - Lnu A-CorrecuHus)

BS - L18! B~Shued

EN - Lu: B-Nonahmd

NP - Neither L‘s! Proton-pica]

PS - Neither Llu-Phonemxcally Similar
UN - Neuher LAelUnrelmed

 

 

 

Discriminability:

_ ‘ —
Nam-luv" M‘s-e-

 

(1 - « ) x 100

=(1 —__)x 100:—

Response Bias:
Whitman-m __

 

— ‘ —
Fill- Punitive. Munc-

Note: I! False Positives - 0 or
Misses - 0. substitute a.
value of 1 when computing
Response Bias.

 

 

M1:sel=18—Hltl=

APPENDIX E

APPENDIX E

The Rivermead Behavioral Memory Test

 

The Rivermead
behavioural memory test

Thames Vallev
Tesr Company

 

Procedural guide and scoring sheet

 

This scoring sheet provides a summary procedure
to ensure that the test is consistently carried-out
in the correcr order.

0 Please follow the instructions in the Manual for
detailed procedural and scoring guidance.

 

Subject and test details

 

Name

Date of birth

 

Date of tesr

Assessment 1 2 3 4
Version A;Redl BIBluel CICreenlDIBrownl

 

 

o 1 and 2 First and Second Name
Action

Present the portrait for ’Remembering a name’.
A Catherine Taylor

B Henry Fisher

C Pauline Roberts

D Philip Goodwin

 

0 3 Belonging

Action

Hide a belonging for ’Rememberini; a hidden
belonging'.

A Desk drawer

B Cupboard

C Filing cabinet

D Brief case or bag

 

- 4 Appointment

Action

Set the timer for ’Remembering an appointment'.
A 'When do I have to see you agarn?’

B 'When does this session end?’

C 'When will I know the results of the tesr?‘

D ‘What time do we finish today-9’

 

0 5 Pictures

Action

Present the ten presentation cards for ’PiCture
recognition’.

 

115

0 6a Story (immediate)

Action

Read the prose passage from the separate Story Sheet.
Then ask the subrecr to recall the prose passage.
Response

Adopt your own technique (eg. underlining and
enCircling‘ for recording each of the 21 ‘ideas’ corrccdv
recalled or partially recalled against the appropriate
passage on the Story Sheet.

Scoring

Scoring is based on points awarded for the number of
'ideas' correctly recalled. You should thererore count
and calculate after the test has been completed.

Raw Score

Each 'idea' recalled word-perfect
or using a close synonym - 1

Each ’idea' partially recalled,
or recalled with approximate
synonym - 'z":

{Maximum - lll

 

Standardised Profile Score
Raw Score
Standardised Profile Score

 

 

 

0 IA
9*
UI

" ‘r
U:
Ui

I») IV
0

Screening Score
Score later

 

- 5 Pictures
Action
Present the 20 recognition cards for ’Picture
recognition'.
Response
Tick each picture identified correctly. (Those pictures
which were previously presented are indicated by
superior figures on the reverse of the pieture cardsl

l 2 3 4 5 6 7 8 9 10

 

Toral

Record the number of false positives

Scoring

Raw Score

SubtrJCt the number of false positives from the
toral number of pietures correCtly identified

IMaXimum - lOl

Smndardised Profile Score

 

Raw Score 58 9 10
Standiirdised Profile Score 0 l 2

 

 

 

‘ Screening Score

All ten pietures identified correcrly with no
false posmves - 1

(Otherwise - Ol

 

 

 

 

116

0 7 Faces

Ammn

Present the five presentation cards for ’Face
recognition'.

0 8a Route (immediate)

Action ' "

Demonstrate the route for ’Remembering a short
route’ (immediate). (Leave the 'Message’ envelope for
’Remembering to deliver a message’ at the location
marked by an asterisk below.) Then ask the subject
to reproduce the route. Record each of the stages
reproduced correctly below. The subject’s response
to ’Remembering to deliver a message’ should be
recorded in the next section.

Response .

Tick each Stage of the route correctly recalled:

 

 

 

 

 

 

A Chair door ' window table‘ chair
B Door window“ table chair door
C Window table 'chair' ‘ door window
D Table ‘ chair f door‘ window table
Scoring 7 ,

. Raw Score

 

 

Total number of stages recalled correctly _- .
(Maximum- 5) .

r Standardised Profile Score _ . ’

Raw Score ' ‘ $3 4 5 g;

. . _ Standardised Profile Score 0 l q ‘. 2. .;
.- *Screening Score *. ' I {5*
O »- All five stages of the route recalled in the
correct order - l - "’

f ‘- (Otherwise- 0)

 

 

 

- 9a Message (immediate)
Action

When demonstrating the route, leave the ’Message’
envelope for ’Remembering to deliver a message’
(immediate) at the location marked by an asterisk
above . .
Response ,

Tick as appropriate

’Message’ envelope picked-up spontaneously

 

 

picked-up after prompt

 

 

 

left at correct location

 

scoring >3- LL ' .--. ..-
‘ Raw Score
'Message’ picked- -up spontaneously- 2
picked- -up after prompt -‘ l
. left at correct location- another 1
(Maximum - 3)

”Standardised Profile Score
.Score later

 

 

 

 

Screening Score
Score later

 

0 7 Faces . ._ ,1 y ,. -
Action ‘ ' ' ' ‘
Present the ten recognition cards for ’Face recognition’.

. Response

Tick each face identided correCtly. (Those faces
which were previously presented are indicated by
superior figures on the reverse of the face cards.)

" i ‘ l 2 ' 3 4 5

 

 

 

 

 

 

 

_—l
Total )

 

 

 

 

Record the number of false positives

Scoring

 

Raw Score

Subtract the number of false positives from the
total number of faces correctly identified

(Maximum- 5)

S tandqrdised Profile Score

Raw Score ‘ $3 4 - 5
Standardised Profile Score 0 l 2

Screening Score
All five faces identified correctly with no false

 

 

 

 

 

 

 

Q

 

 

 

 

 

 

 

 

 

 

 

 

posiuves-i ., w .
, '(Otherwise- 0) Inf-p1 .-- :-

-_ 10 and 11 Orientation and Date ~. -? '
Action 2- ~ . res-5:52:
Ask the ten questions for: ’Orientation and 'Date’ in ; 4 »
the Order given below ~ ‘ r. $33. 1;“: "rg-f - .. ‘ - 5
Response ' " T ' ‘- ‘1' 'i "

Record the subject’ 5 responses in the spaces provrded

1 Year 2 Month - 3 Day of week

4 Date 5 Place 6 City or town

 

 

 

 

 

 

' 9 Prime Minister

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7 Age 8 Year born

10 President

Scoring . L '. ; ..- i ”75-.-
RawScore - ~- -‘ '

 

Score one point for each correct response

0 Total number of correct responses to _ _' _
Orientation questions i.e_. excluding Date .

(Maximum- 9)

0 Count Date

(Maximum - 1)..

 

 

 

 

 

 

 

Standardised Profile Score
0 Orientation questions ’
Raw Score ,
Standardised Profile Score 0 ' l 2 ,

 

 

 

 

 

 

 

U

_-_—__u 4...- <‘_._—_.......-._____..._. .—

117

 

 

 

 

0 Date
Raw Score 5 Two One
days out day out Correcr
Standardised
Profile Score 0 l 2

Screening Score

0 Orientation quesrions

All nine Orientation questions answered
correctly - 1

(Otherwise - 0)

0 Date

Correct Date given - 1

(Otherwise - O)

C

/“\

 

- 4 Appointment
Action

Engage the subject in conversation until the timer
sounds for ’Remembering an appointment’. Prompt
if necessary.

A ’When do I have to see you again?’

B ’When does this session ends”

C ’When will I know the results of the test?’

D ’What time do we finish today?’

Response

Tick as appropriate:

Subject asked appropriate question spontaneously

after prompt

Subject remembered that something had to
be asked but could not remember what it was

 

Scoring
Raw Score
( l Subject asked appropriate queStion
spontaneously - 2
after prompt - 1
Subject remembered that something had to be
asked but could not remember what it was - 1

(Maximum - 2)

Standardised Profile Score
Raw Score 0 l 2
Standardised Profile Score 0

Screening Score

Appropriate question asked without prompt
when timer sounded - 1

(Otherwise- 0)

 

 

 

 

O

0 6b Story (delayed)

Action

 

; Ask the subject to recall the prose passage for ’Delayed
i prose recall’. Give opening prompt if necessary.

Response

Record each of the ’ideas’ correctly recalled or partially
recalled against the appropriate passage on the Story
Sheet

Scoring

Score exactly as for 'lmmediate prose recall’ but
deduct one point if the subject needed an opening
prompt.

 

Raw Score

Each ’idea’ recalled word perfect
or using a close synonym - 1

Each ’idea' partially recalled,
or recalled with approximate
synonym - '/1

(Maximum - 21)

Standardised Profile Score
Raw Score <1 .5 2— 3 5 24
. Standardised Profile Score 0 l 2

Screening Score

If the subject recalled at least six ’ideas' on
’Story (immediate)’ and at least four ’ideas’
on ’Story (delayed)’ - 1

(Otherwise - 0)

l7

 

 

 

 

lb '
\\’ '

 

0 8b Route (delayed) :
Action

Ask the subject to reproduce the route for ’Remem-
bering a short route’ (delayed). Record each of the i
stages reproduced correcrly below. The subject’s
response to ’Remembering to deliver a message' E
(delayed) should be recorder in the next secrion. l
Response '
Tick each stage of the route correctly recalled:

 

 

 

A Chair door window table' chair I
8 Door window‘ table chair door '
C Window table chair‘ door window
D Table chair door' window table
I 5 :
Scoring
Raw Score

 

 

 

Toral number of stages recalled correctly
(Maximum - 5)
Standardised Profile Score

Raw Score s3 4 5
Standardised Profile Score 0 l 2

\ Screening Score
C} All five stages of the route recalled in the
correcr order - 1
(Otherwise - O)

 

 

 

 

 

 

- 9b Message (delayed)

Action

Remind the subiect, if necessary, about the 'Message’

envelope for ’Remembering to deliver a message'

(delayed). The location is marked by an asterisk above.

Response

Tick as appropriate: (_-

'Message’ envelope picked up spontaneously ‘
picked-up after prompt l

l'"’.

left at correct location |

 

Scoring

 

Raw Score - I
1 ’Message’ picked-up spontaneously - 2 ‘
picked-up after prompt - l .
left at correct location - anOther l I
(Maximum - 3)

_

118

 

Standardised Profile Score
The Standardised Profile Score for ’Remem-

 

 

 

bering to deliver a message' is based on the
sum of the Raw Scores obtained for the im-
mediate and delayed recalls (therefore
maximum Raw Score - 6).
Sum of Raw Scores 54 5 6
Standardised Profile Score 0 l 2

Screening Score
If the subject spontaneously picked-up the
'Message’ envelope and left it at the correct
location in the immediate and delayed
recalls - 1
(Otherwise - 0)

\i/1

o 1 and 2 First and Second Name
Action

5 Re-present the portrait for ‘Remembering a name'.

-__-._.-___-__.. _.____.___..______ _ __-

—._--... -.._ . V

-...._...--- ~.. -__—.——_.._. .— -...-. -

Give first letter prompt if necessary.
A Catherine Taylor

B Henry Fisher

C Pauline Roberts

D Philip Goodwin

 

Response
Tick as appropriate
Firsr Name recalled without prompt

 

recalled with prompt

 

 

Second Name recalled without prompt

_—

_l

recalled without prompt - 2

recalled with prompt - 1

(Maximum - 2)

0 Second Name recalled without prompt - 2
recalled with prompt - 1

(Maximum - 2)

Standardised Profile Score

The Standardised Profile Score for 'Remember-
ing a name’ is based on the sum of the Raw
Scores obtained for the recall of the First and
Second Names (therefore maximum Raw
Score - 4).

Raw Score :2 3 4

Standardised Profile Score 0 l 2

Screening Score

0 If the subject recalled the First Name
without prompt - 1

(Otherwise - 0)

0 If the subject recalled the Second Name
without prompt - 1

(Otherwise - 0)

 

recalled with prompt
Scoring

Raw Score
(”—7 0 First Name
L__.

C)

I \\
I

\J
O

0 3 Belonging

Action

Inform the subject that ’We have finished this test’.
Wait for recall of 'Remcmbering a hidden belonging’.
Prompt if necessary.

 

 

 

A Desk drawer

B Cupboard

C Filing cabinet
D Brief case or bag

' ReSponse

Tick as appropriate:
Place recalled without prompt (

 

recalled with prompt

 

Item recalled without prompt

 

 

recalled with prompt
Scoring

77

L—

Raw Score

Place recalled without prompt - 2
recalled with prompt - 1

Item recalled without prompt - 2
recalled with prompt - 1

(Maximum - 4)

Standardised Profile Score
Raw Score 52 3 4
Standardised Profile Score 0 1 2

Screening Score

If the subject spontaneously recalled the item
and the place where it was hidden - 1
(Otherwise - O)

 

 

 

 

O

 

Standardised Screening
Profile Score Score
(2,1 or 0) (l or 0)

<8
G

Score summary

1 First Name >
2 Second Name

3 Belonging

 

 

 

 

 

 

 

 

4 Appointment

 

5 Pietures

6a Story immediate

(WI—l.

6b delayed

 

 

7 Faces

 

8a Route immediate

 

 

8b
9 Message
(immediate & delayed)

10 Orientation
(not including date)

delayed

 

 

 

_l

 

11 Date

 

 

 

Total

 

 

 

 

 

 

 

LIST OF REFERENCES

LIST OF REFERENCES

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Bower, GB. (1970). Analysis of a mnemonic device. American Scientist. :53, 496-510.

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Delis, D.C., Kramer, J H Freeland, J ., & Kaplan, E. ( 1988). Integrating clinical
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,——,

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