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This is to certify that the

dissertation entitled

THE EFFECTS OF ANXIETY AND DEPRESSION ON
MEMORY COMPLAINTS AND MEMORY PERFORMANCE
IN OLDER ADULTS

presented by

Julia Nicholson Crumrine

has been accepted towards fulfillment
of the requirements for

Ph.D. degree in PSYChO] 09y

Mm“. M25,

Major professor

Date December 9, 2002

 

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THE EFFECTS OF ANXIETY AND DEPRESSION ON
MEMORY COMPLAINTS AND MEMORY PERFORMANCE IN OLDER ADULTS

By

Julia Nicholson Crumrine

A DISSERTATION

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

DOCTOR OF PHILOSOPHY
Department of Psychology

2002

ABSTRACT

THE EFFECTS OF ANXIETY AND DEPRESSION ON
MEMORY COMPLAINTS AND MEMORY PERFORMANCE IN OLDER ADULTS

By

Julia Nicholson Crumrine

This study examined how anxiety and depression relate to memory complaints
and memory performance in older adults. Previous research has shown that older adults
exhibiting symptoms of depression tend to present more memory complaints and perform
worse on memory performance tasks than non-depressed older adults. Anxiety, while
more common than depression in older adults, has not been given as comparable attention
in psychological literature. Given that over 34 million people in the United States are
over the age of 65, this is an important area of investigation, especially with over $42
billion being spent for treatment of anxiety disorders in older adults in this country.

The measures used in this study have been shown reliable for use with older
adults (the State-Trait Anxiety Inventory, the Penn State Worry Questionnaire, the Beck
Depression Inventory, the Geriatric Depression Scale, the Memory Assessment Clinics
Self-Rating Scale, and the California Verbal Learning Test). Significant results were
found for two of the nine components of hypotheses. Specifically, when anxiety was
present, participants were more likely to have memory complaints than if anxiety was not
present. Similarly, participants were more likely to report memory complaints if
depression was present than if depression was not present. Also, female participants

were more likely to report high levels of anxiety than male participants were. Additional

results were not statistically significant. The presence of overall anxiety or overall
depression did not impact memory performance. Higher levels of state anxiety did not
impact memory performance. Participation in memory-training workshops did not have
an effect on decreasing memory complaints or increasing memory performance. There
were no gender differences in reports of memory complaints. Also, level of education

did not significantly predict memory complaints or memory performance.

“To believe you can is everything.”

iv

ACKNOWLEDGMENTS

Thank you to all of the faculty, staff, and graduate students of the Department of
Psychology at Michigan State University for the guidance and support you have given me
during my graduate training.

I would like to extend a very special thank you to my advisor, guidance
committee chairperson, and dissertation committee chairperson, Norman Abeles, Ph.D.,
for his assistance and patience during my years at MSU. Also, thank you to the other
members of my dissertation committee, Dozier Thornton, Ph.D., Alexander von Eye,
Ph.D., and Bertram Karon, Ph.D.

Thank you to all of my friends and family members for their endless support and
much needed prayers.

Finally, there are three people who deserve special consideration as I complete
my degree: to my mother, June Nicholson, for giving me the encouragement and ability
to pursue my dream of becoming a psychologist; to Ted Novak, for your constant
friendship and daily telephone calls; and to my husband, Kevin Crumrine, for your love,
your patience, your understanding, and your strength. Without you three incredible

people in my life, this degree would not have happened. Thank you.

TABLE OF CONTENTS

LIST OF TABLES ............................................................................................................ vi
INTRODUCTION ............................................................................................................ 1
Anxiety In Older Adults ........................................................................................ 2
Memory ................................................................................................................. 8
Memory Training .................................................................................................. 11
Gender Differences ............................................................................................... 14
Education .............................................................................................................. 15
HYPOTHESES ................................................................................................................. 17
METHODS ....................................................................................................................... 19
Participants ............................................................................................................ 19
Materials ............................................................................................................... 20
Cut-Off Scores ...................................................................................................... 23
Data Analysis ........................................................................................................ 26
Missing Values ...................................................................................................... 29
RESULTS ......................................................................................................................... 3O
Hypothesis 1 .......................................................................................................... 3O
Hypothesis 2 .......................................................................................................... 31
Hypothesis 3 .......................................................................................................... 32
Hypothesis 4 .......................................................................................................... 33
Hypothesis 5 .......................................................................................................... 33
General Findings ................................................................................................... 34
DISCUSSION ................................................................................................................... 36
Anxiety and Depression ........................................................................................ 36
Memory Complaints and Memory Performance .................................................. 36
Gender Differences ............................................................................................... 37
Education .............................................................................................................. 39
Memory Training .................................................................................................. 40
Results Found in Predicted Direction ................................................................... 41
Methodological Concerns / Limitations of Study ................................................. 43
Broader Implications ............................................................................................. 46
APPENDIX ....................................................................................................................... 49
REFERENCES ................................................................................................................. 64

vi

LIST OF TABLES

Table l - 2 x 2 Cross—Classification of Anxiety and Memory Complaints ...................... 52
Table 2 - Cut-off Scores for Measures .............................................................................. 53
Table 3 - Results of Hypothesis 1, Component 1 ............................................................. 54
Table 4 - Results of Hypothesis 1, Component 2 ............................................................. 55
Table 5 - Results of Hypothesis 2 ..................................................................................... 56
Table 6 - Results of Hypothesis 3, Component 1 ............................................................. 57
Table 7 - Results of Hypothesis 3, Component 2 ............................................................. 58
Table 8 - Results of Hypothesis 4, Component 1 ............................................................. 59
Table 9 - Results of Hypothesis 4, Component 2 ............................................................. 60
Table 10 - Results of Hypothesis 5, Component 1 ........................................................... 61
Table 11 - Results of Hypothesis 5, Component 2 ........................................................... 62

vii

INTRODUCTION

With about 34.7 million adults over the age of 65 in the United States, it is
important to gain a better understanding of physical and psychological concerns of older
adults. Common concerns include changes in physical health, memory complaints, as
well as psychological symptoms including anxiety. Based on a prevalence rate for
Anxiety Disorders in the elderly of around 11.4% in the United States, we can estimate
that over 3.9 million older adults experience symptoms of anxiety severe enough to meet
criteria for diagnosis. These numbers only reflect the number of older adults who meet
criteria for diagnosis. It is important to note that many more older adults experience
symptoms of anxiety which affect daily functioning. Specific symptoms of anxiety will
be described later. The experience of anxiety is likely to be unpleasant and based upon
feelings that range from uneasiness to apprehension to terror. People experiencing
feelings of anxiety are unlikely to be able to give a precise explanation as to the source of
their fear. Instead, they describe their experience as a worry or concern that appears to be
out of their control. This experience can be so unpleasant that they seek treatment to
alleviate symptoms.

With regard to anxiety, Greenberg et a1. (1999) estimated the annual cost of these
disorders in the United States to be about $42.3 billion dollars, or about $1542 per
patient. These authorities reported that psychiatric treatment, prescription medication,
and nonpsychiatric medical treatment make up about 66% of this estimate (or about
$1018 per patient). That means that the cost of treating anxiety disorders in the 3.9
million older adults is about $3.97 billion. In addition, most of the nonpsychiatric

medical treatment usually comes as result of misdiagnosing physical symptoms as other

medical conditions, rather than anxiety. Research is needed to examine the effects of
anxiety on memory functioning and memory complaints since memory functions and
memory complaints impact the quality of life of older adults since anxiety is evidently
treatable.

Older adults often report that their memory has changed since early adulthood.
This current study investigated memory complaints as well as memory performance in
older adults. Memory complaints are subjective reports regarding older adults’
perceptions of memory ability. Frequently, complaints focus on difficulty with
remembering names, location of objects (e. g., keys, wallets, or eyeglasses), or scheduled
appointments. In this study, older adults reported on their memory ability, as compared
to their peers. Memory performance, however, is an objective measure of memory
ability. For example, memory performance can be measured by providing a list of words
for an individual to remember and asking the individual to recall as many words as
possible. This type of memory ability relies on verbal memory (i.e., memory that is
dependent on language skills). There are other types of memory, like visual memory,
spatial memory, or motor memory. These memory types were not examined in this
current investigation. Rather, this current study focused on verbal memory, specifically
word lists.
AnxietLin Older Adults

Previous research has suggested that, as a group, older adults experience less
anxiety and stress than their younger counterparts (Beck & Stanley, 1997; Stanley, Beck
& Zebb, 1996). Although, anxiety disorders are significantly more prevalent than mood

disorders in older adults (Beck & Stanley, 1997; Fuentes & Cox, 1997; Stanley, Beck &

Zebb, 1996; Wetherell & Arean, 1997), the current psychological literature focuses less
attention to investigating and explaining anxiety, in comparison to mood disorders, in
adults over 65 years.

An examination of the literature on anxiety disorders in older adults showed that
Generalized Anxiety Disorder (GAD) is the most common anxiety disorder found in
older adults (Beck & Stanley, 1997; Beck, Stanley, & Zebb, 1996; Stanley, Beck, &
Glassco, 1996; Stanley Beck, & Zebb, 1996). GAD is characterized primarily by
excessive anxiety and worry, resulting in cognitive and physical symptoms (e.g., muscle
tension, fatigue, irritability) severe enough to cause impairment in functioning (DSM-IV:
APA, 1994). One difficulty in diagnosing older adults with GAD arises from the
physical symptom components. Hersen, Van Hasselt, and Goreczny (1993) noted that
older adults present physical symptoms (e. g., increased heart, pulse, and respiration rates)
which can be attributed to other medical conditions. These symptoms can be mistaken
for anxiety. Conversely, symptoms of anxiety can be mistaken for other medical
conditions.

In assessing anxiety in adults, some of the behavioral measures include a physical
complaint component. Specifically, the Hamilton Anxiety Rating Scale (HARS) has
been criticized for depending too much upon somatic complaints (Beck & Stanley, 1997).
Other measures of anxiety have been tested for use with an older adult population.
Stanley, Beck, and Zebb (1996) investigated the State-Trait Anxiety Inventory (STAI),
the Worry Scale (WS), the Padua Inventory (PI), and the Fear Questionnaire (F Q) for use
with older adults. They found these measures appropriate for use with older adults.

They cautioned, however, that further validating processes are needed before these

measures can be utilized with older adults. Wetherell and Arean (1997) examined the
utility of the Beck Anxiety Inventory (BAI) for older adults. While their sample included
older medical outpatients with low income, they found the BAI to be effective in
identifying anxious symptoms for this group. They suggested that further research needs
to be conducted with the BAI to be able to utilize this measure for use with an older adult
population.

Most of the literature reflects the notion that anxiety disorders in older adults is an
underinvestigated area given its prevalence. Comparatively, the investigation of anxiety
disorders for younger adults is well established and well documented, as is the
investigation of depression in older adults. The DSM-IV does not distinguish between
age groups for the diagnosis of Generalized Anxiety Disorder (GAD). Research suggests
that the etiology and course of GAD is different for older adults. While the diagnostic
criteria are the same for all age groups, it seems that the etiology as well as specific
symptoms and complaints differ between age groups. For example, older adults tend to
have more physical complaints than their younger counterparts. Another complication to
studying anxiety (in both older and younger adults) is the problem of comorbidity with
depression (Mineka, Watson, & Clark, 1998). In addition, anxiety and depression
frequently have overlapping symptoms, making a single diagnosis for either disorder
more challenging. Comorbidity will be discussed in later sections.

The current literature focusing on anxiety disorders in older adults presents a wide
range of characteristic symptoms. Beck et a1. (1996) noted the lack of previous research
on GAD in older adults. Their research was designed to address the limited literature as

well as to prompt further research in this area. The GAD sample included 44 adults (30

women, 14 men) from 55 to 81 years of age who met DSM-III-R criteria for GAD. Forty
one participants were Caucasian; two participants were African American; and one was
Hispanic. The normal control participants were matched for age, gender, and ethnicity
(30 women, 14 men; 41 Caucasian, 2 African American, 1 Hispanic). Beck et al. (1996)
used four measures of anxiety (the State Trait Anxiety Inventory [STAI], the Worry
Scale [WS], the Hamilton Anxiety Rating Scale [HARS], and the Penn State Worry
Questionnaire [PSWQ]), two measures of depression, and one measure of fear (the Fear
Questionnaire [F Q]). They found that the Generalized Anxiety Disorder (GAD) group
scored significantly higher on all scales of anxiety and depression and on the social
subscale of the fear measure. Beck et a1. suggested that compared to older adults without
mental disorders, older adults with GAD reported “elevated levels of anxiety, worry,
depression, and social fears” (p. 231). In a closely related study, Stanley, Beck, and Zebb
(1996) found no significant differences on measures of anxiety (STAI, WS, FQ, and PI)
between older and younger adults with GAD. They cautioned, however, against
generalizing these results given small sample sizes and the nature of mean scores.
Wetherell and Arean (1997) examined symptoms of anxiety in older adults
although not specifically GAD. However, their findings offer clues regarding areas in
which older adults tend to feel anxious. They suggested that anxiety includes four
factors: cognitive, autonomic, neuromotor, and panic. These symptom areas are made
up of several variables. Cognitive variables (symptoms) included unable to relax, fear of
the worst happening, terrified, nervous, fear of losing control, fear of dying, and scared.
Autonomic variables included unable to relax, feeling hot, indigestion or discomfort in

abdomen, face flushed, and sweating (not due to heat). Neuromotor variables included

numbness or tingling, wobbliness in legs, dizzy or lightheaded, unsteady, hands
trembling, shaky, and faint. Panic variables included heart pounding or racing, feelings
of choking, and difficulty breathing. The above symptoms were characteristic of the
symptoms of anxiety in older medical patients and are congruent with DSM-IV criteria
for GAD.

Comorbidity of anxiety with other disorders is also a concern for younger as well
as older adults. Mineka, Watson, and Clark (1998) examined the relationship between
anxiety and depression, since these disorders tend to occur more often with each other
than with other disorders. These disorders share common physical symptoms: fatigue,
difficulty concentrating, and/or sleep disturbances. In addition, these disorders share
general negative affective components that can make distinguishing between them
troublesome. Mineka, Watson, and Clark described Clark and Watson’s (1991) Tripartite
Model to explain the relationship between of anxiety and depression. According to this
model, symptoms of anxiety and depression are viewed in three factors. First, the
General Distress/Negative Affect factor contains the symptoms common to both anxiety
and depression. Research has shown (Clark & Watson, 1991; Mineka, Watson, & Clark,
1998; and Watson, et al., 1995) that this factor includes symptoms which are nonspecific
to each disorder: depressed affect, anxious affect, poor concentration, restlessness, sleep
disturbances, and irritable mood. These symptoms occur in both diagnoses of anxiety
and depressive disorders and are described generally as being components of negative
affect. Second, the Somatic Tension and Hyperarousal factor accounts for symptoms
unique to anxiety. These symptoms include mostly physical presentations of somatic

tension and hyperarousal often seen in anxiety disorders and associated with common

panic disorder-like symptoms: lightheadedness, shortness of breath, trembling, and dry
mouth. Finally, the Anhedonia and Absence of Positive Affect factor includes symptoms
which are unique to depression. These symptoms include the loss of interest or ability to
experience pleasure, fatigue, as well as the lack of positive affect.

The General Distress/Negative Affect component is of particular interest in this
current investigation as it includes symptoms harmful to memory: poor concentration
and restlessness. Basso and Bornstein (1999) found that recurrent depression can impair
memory functioning as measured by the California Verbal Learning Test (CVLT) in
younger adults. Other studies have shown that depression can impair memory
functioning in younger and/or older adults (Burt, Zembar, & Niederehe, 1995, and
Deptula, Singh, & Pomara, 1993). Additional studies have shown that depression in
older adults can impair memory functioning (Cipolli et al., 1996, and King, Cox, Lyness,
Conwell, & Caine, 1998) as well as increase memory complaints (Collins & Abeles,
1996, and Bassett & Folstein, 1993). This current investigation is designed to discover
whether similar results on memory functioning and memory complaints are found with
anxiety.

When discussing anxiety, it is important to note that anxiety is often broken down
into two components: state anxiety and trait anxiety. Levy-Cushman, McBride, and
Abeles (1999) reported that Cattell and Scheier (1961) were the first to distinguish
between these concepts. State anxiety includes feelings of anxiety which are dependent
upon the current situation. These feelings are likely to change with a change in the
situation. Trait anxiety refers to feelings of anxiety that are more persistent, are more

likely to represent overall feelings of anxiety, and are not directly state-dependent. The

presence of trait anxiety increases the likelihood of state anxiety during stressful
situations.
Memog

In addition to presenting symptoms of anxiety, older adults often have memory
complaints, including difficulty remembering location of car keys or eyeglasses, names
of people and places, as well as significant past events. Ritchie, Ledésert, and Touchon
(2000) reported that memory complaints and memory problems in older adults are not
necessarily due to aging since the definition of “normal” aging has changed with
improvements in general physical health, including better health care and better nutrition.
When comparing scores on cognitive functioning tests between older and younger adults,
frequently cross-sectional research does not take differences between generations (cohort
effects) into account. They suggested that longitudinal studies, which follow the same
group of individuals over a long period of time, show little cognitive decline in the
participants. For individuals who do show such decline, there is a difference in the type
of decline demonstrated. That is, older adults may or may not show decline in one or
more of the following areas: attention, language, working memory, or secondary
memory. Older adults may show decline in any combination of these areas but not
necessarily in all of these areas.

Derouesné, Lacomblez, Thibault, and LePoncin (1999) investigated the difference
in memory complaints in younger and older adults. Participants were recruited through
newspaper, radio, and television media as well as through referrals and administered a
screening examination which consisted of an interview, subjective memory complaints

questionnaires, objective memory tests, and depression and anxiety self-report

questionnaires. Participants who acknowledged memory complaints but showed no
cognitive impairment and no medical illness and/or psychological disorders were
included in the study. Participants were then divided into two groups: younger adults
and older adults, with 50 years old being the determining age. Over the course of 12
months, 260 participants were included in the study. The younger group included 77
participants and had a mean age of 39 years (range=20—49). The older group included
183 participants and had a mean age of 61 .1 years (range=50—85). Derouesné et al.
found no difference between the groups on cognitive performance but found that younger
adults reported significantly higher depression and anxiety scores than the older adults.
Furthermore, they found that while the groups were similar in overall subjective memory
complaints, younger adults ranked their memory complaints as more severe and of longer
duration than older adults did. They also reported that memory complaints were related
to memory performance only in older adults with major complaints. That is, there was no
significant relationship between memory complaints and memory performance for older
adults with minor complaints or for younger adults with either major or minor
complaints. In addition, they found that participants endorsing anxious symptoms were
statistically more likely to report major memory complaints.

Research has shown that memory complaints are related to memory performance
(Levy-Cushman & Abeles, 1998, and Jonker et al., 1996). They suggested that
community-dwelling able elderly are able to identify their level of performance,
especially when comparing their current level to previous ones. Other studies have
shown that the severity or intensity of complaints contribute to memory performance

(Hanninen et a1, 1994, and Derouesné et al., 1999). That is, the more older adults

indicate that they have memory problems, the more they show lower levels of
performance. Other factors may be influencing the scores on memory performance tests
(e.g., symptoms of anxiety and/or depression). It seems that when older adults show
more memory complaints, they also report higher levels of anxiety as well as depression.
F003 (1997) reported a relationship between symptoms of anxiety symptoms and memory
complaints in older adults. Further, memory complaints tend to decrease with the
alleviation anxious symptoms. In addition, Jonker, Smits, and Deeg (1997) studied
adults between the ages of 65 and 85 and reported that higher levels of anxiety were
related to poorer memory performance in this age group. Based on the previous research,
there seems to be a relationship between memory complaints and memory performance,
anxiety and memory complaints, and anxiety and memory performance.

Bassett and F olstein (1993) examined 810 adults aged 18 to 92 to compare
younger and older adults with respect to subjective memory complaints, objective
memory performance, and psychiatric diagnosis. They found that overall, 22.1% of
participants reported memory complaints while 11.6% showed poor memory
performance as measured by the three item recall task on the Mini-Mental State
Examination. Of adults ranging in age from 18 to 44, 14.5% reported memory
complaints while 4.7% demonstrated poor memory performance. Of adults aged 45 to
64, 19.6% reported memory complaints while 11.9% demonstrated poor memory
performance. The difference between this younger age group was not significant.
However, older adults in each of the following age ranges differed significantly from
each other. Of older adults between the ages of 65 to 74, 42.7% reported memory

complaints and 25.5% showed poor memory performance. Of 75 to 84 year olds, 50.8%

10

reported memory complaints and 39.7% showed poor performance. Finally, of adults 85
and older, 88.3% reported memory complaints and 43.6% showed poor performance.
Bassett and F olstein found that memory complaints increase with age while memory
performance decreases with age. When examining the effects of psychiatric diagnosis,
they did not divide participants into age groups. The following figures represent their
whole sample. Psychiatric diagnoses were made based on clinical interviews by a
psychiatrist who used DSM-III diagnoses. Of participants receiving a diagnosis, 5.8%
were diagnosed with Affective disorders and 17.2% were diagnosed with Anxiety
disorders. Of participants with Affective disorders, 34.2% reported memory complaints
and 6.6% performed poorly on the memory performance task. Of participants diagnosed
with Anxiety disorders, 27.2% reported memory complaints while 6.9% performed
poorly on performance tasks. Of participants with no diagnosis, 18.6% reported memory
complaints with 10.1% demonstrating poor performance. Bassett and F olstein did not
report age groups with diagnoses so it is not clear how many participants diagnosed were
older adults. Nevertheless, there was a significant difference between memory
complaints and memory performance for those participants with Affective and Anxiety
disorders. Other disorders were not statistically significant with regard to the relationship
between complaints and performance. Participants with Affective disorders or Anxiety
disorders were more likely to show a disparity between complaints and performance than
participants with no diagnosis or with other diagnoses.
Memory Training

Andrewes, Kinsella, and Murphy (1996) found that memory-handbook training

significantly improved memory performance in older adults. Participants were 20 men

11

and 20 women randomly assigned to treatment and control groups. All participants were
administered a series of tests for screening purposes and another series to establish pre-
treatment baselines. The Mattis Dementia Rating Scale was used as a dementia
screening; the Rey Auditory Verbal Learning Test and the Warrington Forced-Choice
Recognition for Faces were used to measure memory; the Beck Depression Inventory
was used to measure emotional affect; and the National Adult Reading Test was used to
estimate intellectual level. Finally, participants provided information regarding
education level. There were no significant differences between the groups on screening
measures. Next, all participants were administered a pre-test to establish baseline
functioning. These assessments evaluated memory in the following areas: face-name
learning, prospective memory (laboratory and everyday tasks), and memory strategy
knowledge. In addition, both groups were instructed to complete a memory diary,
including the frequency of remembered and forgotten tasks from a checklist of situations,
during the week prior to post-testing. The treatment group was then provided memory
strategies in the following areas: remembering names, future activities, location of
placed objects, verbal information (lists and prose), how to get somewhere, and series of
meaningful numbers. The strategies were provided in a handbook form as well as during
a 30-minute training session. The control group was given a less useful but face valid
pamphlet on mnemonics. All participants were encouraged to utilize the memory
strategies for one month before returning for testing. Post-testing revealed significant
differences between the groups. Specifically, the treatment group performed better on
the face-name learning task and endorsed more strategy knowledge items than the control

group. In addition, the treatment group showed significantly better performance on the

12

to-be-remembered tasks taken from the memory diary than the control group. There
were no significant differences between the groups for prospective memory, either
laboratory or everyday tasks. Andrewes et al. concluded that the memory handbook and
training provided older adults with memory strategies that were useful in everyday
situation tasks.

De Vreese, Belloi, Iacono, Finelli and Neri (1998) also examined the
effectiveness of memory training with older adults. Participants were 18 men and 41
women selected from community-dwelling members of an association of retired persons.
After undergoing screening for cognitive impairment, clinical depression, and biological
factors which could impair memory, participants were assessed for objective and
subjective memory functioning and mood. De Vreese et al. used two memory measures
validated for use with older adults. The Randt Memory Test (Randt, Brown, &
Osbourne, 1980) assessed objective memory in seven areas: general information, list
learning, forward and backward digit span, paired associates, prose memory, picture
recognition and verbal recall, and incidental learning. The Sehulster Metamemory Scale
(Sehulster, 1981) assessed subjective memory through self-report in the following areas:
past memory functioning as compared to current memory functioning, memory loss
complaints, and memory functioning as compared with peers. Finally, participants
completed a validated self-report questionnaire which detects affective disorders. Based
on screening measures, participants were placed into one of two groups: subjective
memory complainers (SMC) and those experiencing aging-associated cognitive decline
(AACD). The SMC group consisted of 12 men and 27 women with a mean of 10.9 years

of education. The AACD group consisted of 6 men and 14 women with a mean of 10.6

13

years of education. While both groups reported memory problems, only the AACD
group showed objective cognitive decline. Participants were then randomly assigned to
treatment groups in which they attended weekly 90-minute memory training sessions for
three months. F ifty-nine participants (18 men and 41 women) completed pre- and post-
testing as well as all training sessions. Participants were taught mnemonic techniques
and learning strategies designed to assist in memory of people’s names, location of
placed objects, prospective memory, and recall of information and facts. In addition,
participants were shown methods of increasing awareness of memory functioning as well
as methods of COping with memory complaints. After memory training sessions,
participants returned for post-testing. De Vreese et al. found that memory training
sessions significantly improved objective memory performance in both SMC and AACD
groups. In addition, memory training sessions significantly improved subjective memory
complaints. Both groups seemed to have benefited from memory training sessions in
objective memory performance as well as subjective memory complaints. Furthermore,
participants showed significant improvement in measures of affective well-being though
it is not certain whether the improvement was due to the content of the memory training
sessions or the experience of being involved in the group sessions.
Gender Differences

Gender has been shown to be a factor in anxiety with older women reporting
more anxiety than older men (Fuentes & Cox, 2000; Morin et al., 1999). Morin et al.
examined 281 adults (177 women, 104 men) over 55 years old, using the Beck Anxiety
Inventory (BAI). Women scored significantly higher (indicating more anxiety) than men.

Similarly, Fuentes and Cox examined 84 adults (39 women, 45 men) over the age of 67,

14

using three measures of anxiety (Anxiety Sensitivity Index, Fear Questionnaire, and the
State-Trait Anxiety Inventory). Older women scored higher than older men on all three
measures of anxiety. Also, according to the DSM-IV, Generalized Anxiety Disorder
(GAD) is found more often in women than men, with about 55 to 60 percent of patients
diagnosed with GAD are women (APA, 1994). While differences on anxiety measures
cannot be assumed based solely on gender, there appears to be enough support from
previous research to investigate this area in the current study.
Education

Education has been shown to serve as a protective factor in cognitive functioning
with individuals with higher levels of education showing less decline than individuals
with lower levels of education (Compton, Bachman, & Logan, 1997). Compton,
Bachman, and Logan examined the effects of aging and intellectual ability with college
faculty members as their participants with an age range of 25 to 72 years old, using a
range of measures which included tests of memory, intelligence, attention, and
processing speed. The results showed that the older faculty members performed worse
on measures requiring psychomotor speed. This finding is consistent with previous
research. However, they did not find significant age-related differences on other
measures that do not require psychomotor speed. This finding is contrary to previous
research with older adults. The difference, it seems, is that the participants in this study
were highly educated college faculty who most likely engaged regularly in cognitive
tasks. Compton, Bachman, and Logan suggested that education and cognitive activity
may enhance the performance in older adults. Also, they suggested that educated and

cognitively active older adults may be able to counteract age-related cognitive decline or

15

that education and cognitive activity may protect older adults from cognitive decline.
This study provides some encouragement for older adults to continue to engage in
cognitive activities throughout their life span. It is possible that cognitive deficits found
in older adults might be due partly to the general psychomotor slowing and not

necessarily to an inevitable cognitive decline.

l6

HYPOTHESES

There seems to be a relationship between performance on memory tests as well as
reported memory complaints in older adults when either anxiety or depression is present.
Also, education levels and gender differences seem to have some association with
reported complaints and reported symptoms of anxiety and depression. This current
study is designed to examine these relationships.

In light of the preceding review of the literature, this current investigation will
examine the relationship between symptoms of anxiety and depression and memory
complaints and symptoms of anxiety and depression and memory performance, as well as
the relationship of demographic factors (specifically, gender and education) with anxiety
and memory scores.

The following hypotheses were tested in this current investigation:

Hypothesis 1: Participants who endorse anxiety and depression symptoms will be more

 

likely to report more memory complaints and show poorer memory performance than
participants who do not endorse anxiety and depression symptoms. This relationship was
tested using the scores from the anxiety measures: the State-Trait Anxiety Inventory
(STAI) and the Penn State Worry Questionnaire (PSWQ), the scores from the depression
measures: the Beck Depression Inventory (BDI) and the Geriatric Depression Scale
(GDS), and the scores from the memory measures: the Memory Assessment Clinics Self-
Rating Scale (MAC-S) and the California Verbal Learning Test (CVLT).

Hypothesis 2: Participants reporting higher levels of anxiety symptoms at the time of

 

testing will score lower on the memory test than participants reporting lower levels of

17

anxiety symptoms at the time of testing. This relationship was measured using the scores
from the STAI (State) and the CVLT.

Hypothesis 3: Participation in memory-training workshops is expected to reduce the
number of memory complaints as well as increase scores on the memory functioning test.
This effect was measured by comparing the MAC-S and CVLT scores from pre- and
post-testing, after the participants participated in memory training workshops.

Hypothesis 4: Gender differences are expected with anxiety symptoms affecting memory

 

complaints more in women than in men. In addition, women are expected to report more
symptoms of anxiety than men report. Gender differences were Studied using the
demographic information as well as scores from the MAC-S, STAI, and PSWQ.

Hypothesis 5: Level of education differences are expected with individuals with higher

 

levels of education showing fewer memory complaints and better memory performance
than individuals with lower levels of education, independent of symptoms of anxiety and
depression. This effect was measured using demographic information, MAC-S, and

CVLT.

18

METHODS

Participants

This current study collected data from participants in the Michigan State
University Mood and Memory Project. Community dwelling older adults were recruited
through newspaper advertisements and mailings. Participants were administered a wide
range of neuropsychological tests, with particular focus on attention, concentration, and
memory. In addition, participants completed several self-report questionnaires regarding
symptoms of depression and anxiety as well as a demographic worksheet. After testing,
the participants attended seven mood and memory workshops geared to address concerns
in these areas and offer strategies to assist participants in coping with these issues.
Participants then returned for testing to measure changes in cognitive and emotional
functioning. There were 59 participants who completed testing and the workshops in this
order (pre-test, workshop, post-test). In order to establish a control group, some
participants were administered both pre- and post-tests before participating in the
workshops. There were 13 participants who completed both testing sessions prior to
attending the workshop. In addition, there were 28 participants who completed pre-
testing and dropped out of the research project. The post-testing scores were imputed for
these participants using the NORM for Windows 95/98/NT program which will be
described later in this section. These 28 participants were included in the control group
for a total of 41 participants who did not attend the workshops.

Participants included 100 adults between the ages of 51 and 91 (M = 67.82; SD =
8.76). There were 39 males and 61 females, with between 5 and 21 years of education

(M = 15; SD = 3.23). The mean age of male participants was 68.08 years (SD = 7.72)

19

with a mean education of 16.23 years (S_D = 3.03). The mean age of female participants
was 67.66 years (S_D = 9.42) with a mean education of 14.21 years (S_D = 3.12).

Participants were administered the battery of tests at two separate times: once
within one week before the mood and memory workshop which lasted approximately
four weeks and once within one week following the workshop. Each testing session took
approximately two hours. During testing sessions, participants completed a demographic
questionnaire as well as all testing materials. The mood and memory workshops were led
by clinical psychology graduate students for up to 10 participants per group. Each
session of the workshops lasted 75 to 90 minutes. Sessions were offered two times
weekly for a total of seven sessions over a four week period. A description of measures
relevant to the current study as well as a description of each workshop session will
follow.

Materials

Measures. The following anxiety measures were used from the complete battery
of research instruments:

1) State-Trait Anxiety Inventory (STAI; Spielberger, Gorsuch, & Lushene, l970)——This
self-report questionnaire consists of 20 items regarding current feelings and 20 items
regarding general feelings. Subjects respond using a four point scale. Stanley, Beck,
and Zebb (1996) reported substantial test-retest stability (.84 trait, _13<.001) with older
adults. In addition, the STAI seems to have considerable internal consistency with
older adults (0t=.85 state, 0t=.79 trait).

2) Penn-State Worry Questionnaire (PSWQ; Meyer, Miller, Metzger, & Borkovec,

l990)——This self-report measure consists of 16 items to which participants respond

20

1)

2)

on a five point Likert scale ranging from “not at all typical of me” to “very typical for
me.” Meyer et al. (1990) reported different convergent validity with the STAI-Trait,
r(389)=.64, than with the STAI-State, r(395)=.49, or the BDI, [(154)=.36. Meyer et
al. reported good test-retest reliability r(45)=.92. Beck, Stanley, and Zebb (1995)
examined the PSWQ’s psychometric properties with older adults. Participants
included older adults with Generalized Anxiety Disorder (n=47, mean age=67.9) and
normal controls (n=94, mean age=67 .5). The PSWQ showed good internal
consistency with both groups (GAD (1:803 and control 0L=.8O3). In addition, they
found good convergent validity with the PSWQ correlating significantly with the
STAI-T (.38), the STAI-S (.56), and the BDI (.45) in the control group.

The following depression measures were used:
Geriatric Depression Scale (GDS; Yesavage et al., 1983)—This self-report
questionnaire consists of 30 items with a “yes” or “no” response for each item. Test-
retest reliability showed a correlation of .85 (p<.001) after a one week delay between
administrations. Convergent validity between the Zung Self-Rating Scale of
Depression (_r=.86) and the Hamilton Rating Scale for Depression (r=.83) was found
for the GDS. In addition, the GDS showed good internal consistency (_r=.83) and
stability with older adults.
Beck Depression Inventory (BDI; Beck, Ward, Mendelson, Mock, & Erbaugh,
l961)—This self-report questionnaire consists of 21 items on a four point scale.
Beck et al. (1961) reported good internal consistency (r=.93). Miller and Seligman
(1973) reported good test-retest reliability (r=.74) with older adults afier a three

month delay between administrations. Spitzer, Endicott, and Robbins (1978)

21

1)

2)

reported that the BDI has shown good internal consistency and stability with research
of older adults.

Finally, the following memory measures were used:
California Verbal Learning Test (CVLT; Delis, Kramer, Kaplan, & Ober, 1987)—
This test consists of 16 items presented five times as a shopping list, with immediate
and delayed recall. Lezak (1995) reported split-half reliability correlation
coefficients ranging from .77 to .86.
Memory Assessment Clinics Self-Rating Scale (MAC-S, Crook & Larrabee, 1990,
l992)—This self—report questionnaire measures subjective memory complaints using
21 Ability items, 24 Frequency of Occurrence, and four Global Rating of memory
problems. Subjects respond using a 5-point Likert scale. Lezak (1995) reported that
normative data was developed based on over 1,000 adults, age 18 to over 70 years.
Lezak also reported that Crook and Larrabee (1991) found test-retest reliability
between .82 and .94 across 3 weeks.

The above measures have been shown reliable and valid for use in an older adult

population. In addition, demographic information on gender and education was also used.

Memory Training Workshops. After completing pre-testing, participants attended

a seven session training group that met twice weekly for 75 to 90 minutes each session.

The number of participants ranged from five to ten per workshop. A list of training

provided at each session is provided in Appendix A. During each session, participants

were encouraged to discuss current concerns with changes in their memory. The

workshop facilitator provided materials for improving memory ability and encouraged

participants to practice memory skills between sessions. Memory techniques included

22

mnemonic training exercises for word lists (e.g., the Method of Loci), paragraphs (e. g.
Preview-Question-Read-Summarize-Test method), and names of people (e. g., names-face
association method). The facilitator began each session by asking participants to describe
their level of practicing the previous session’s techniques. Also, the facilitator taught
relaxation techniques in session and asked that participants practice between sessions.
Relaxation techniques included guided imagery, progressive muscle relaxation, and
meditation. After completing the seven session workshop, participants returned within
one week for post-testing.

Cut-off Scores

In order to categorize the data for later odds ratio utilization, cut-off scores were
determined based on the literature for each of the seven variables. The information is
summarized in Table 2.

State-Trait Anxiety Inventory (STAI). Higher scores on this self-report measure
suggest higher levels of anxiety in both the state and the trait conditions. Using the
results from Stanley, Novy, Bourland, Beck, and Averill (2001) a cut-off score of 37 was
used for State anxiety and 46 for Trait anxiety. Stanley, Novi, et al. studied adults age 60
to 80 years. Scores of 37 on State anxiety and 46 on Trait anxiety represent one standard
deviation from the mean for reported anxiety. All State anxiety scores greater than or

6619’

equal to 37 were converted to to indicate that State anxiety was present; scores below

37 were converted to “O” to indicate that State anxiety was not present or was low. In the

6619’

same way, Trait anxiety scores equal to or greater than 46 were converted to to
indicate that Trait anxiety was present; scores below 46 were converted to “2” to indicate

that Trait anxiety was not present or was low.

23

Penn-State Worry mestionnaire (PSWQL Higher scores on the self-report
measure suggest higher levels of anxiety. Using the results from Stanley, Novy, et al., a
cut-off score of 53 was used. A score of 53 represents one standard deviation from the

661’,

mean for reported anxiety. Scores equal to or greater than 53 were converted to to
indicate that anxiety was present; scores below 53 were converted to “2” to indicate there
was little or no anxiety reported.

Total Anxiety Score (TAS). If participants showed the presence of anxiety in
STAI-State, STAI-Trait, or PSWQ tests based on the cut-off categories, then the TAS
was “1” to indicate the presence of anxiety. If participants did not show the presence of
anxiety, then the TAS was “2” to indicate little or no anxiety.

Geriatric Depression Scale (GDS). Higher scores on this self-report measure
suggest higher levels of depression. According to the GDS manual, scores from O to 9
indicate normal responses. Scores from 10 to 19 suggest mild depression while scores
above 19 suggest severe depression. Therefore, a cut-off score of 10 was used in this

‘61,,

current investigation. Scores equal to or greater than 10 were converted to to
indicate that depression was present; scores below 10 were converted to “2” to indicate
little or no depression.

Beck Depression Inventory (BDI). Higher scores on this self-report measure
suggest higher levels of depression. According to the BDI manual, scores from 0 to 9
suggest normal responses. Scores from 10 to 15 suggest minimal depression. Scores

above 15 suggest mild-moderate, moderate-to-severe, or severe depression. Therefore, a

cut-off score of 16 was used. Scores greater than or equal to 16 were converted to “l” to

24

indicate the presence of depression; scores below 16 were converted to “2” to indicate
minimal or no depression.

Total Depression Score (TDSL If participants showed the presence of depression
in either the GDS or BDI tests based on the cut-off categories, then the TDS was “1” to
indicate the presence of depression. If participants did not show the presence of
depression, then the TDS was “2” to indicate little or no depression.

California Verbal Learning Test (CVLT). Higher scores on this clinician-
administered measure indicate better memory. Based on normative data for older adults
(Paolo, Troster, & Ryan, 1997a and Paolo, Troster, & Ryan, 1997b), a cut-off score of 4
was determined (mean = 5.89, SD = 1.82). Scores equal to or less than 4 were converted

‘61”

to to indicate poor memory performance; scores above 4 were converted to “2” to
indicate normal or good performance.

Memom Assessment Clinics Self-Rating Scale (MAC-8L Higher scores on this
self-report measure indicate fewer memory complaints. Based on normative data (Crook
& Larrabee, 1992), a cut-off score of 52 was determined for the Ability subtest, which
measures the participant’s ability to remember specific types of information. A score of
52 was approximately one standard deviation from the mean for ages 50 and above.
Scores equal to or less than 52 were converted to “1” to indicate the presence of memory
complaints; scores greater than 52 were converted to “2” to indicate little or no memory
complaints.

Levels of education. Participants with up to 12 years of education were placed in

the High School group. Participants with between 13 and 16 years of education were

25

placed in the College group. Participants with over 17 years of education were placed in
the Graduate Work group.
Data Analysis

We employed the following statistical procedures to test hypotheses. For
Hypothesis 1, Hypothesis 3, and Hypothesis 4, we used odds ratios to analyze the data.
Rudas (1998) and von Eye and Schuster (2000) describe the method of testing each
participant’s pattern of responses with the hypothesis. By categorizing the data, we were
able to assign a specific pattern of responses for each participant. That pattern, then, was
tested with the hypothesis. For example, in Hypothesis 1, we categorized the four
variables (viz., Anxiety, Depression, Memory Complaints, and Memory Performance) as
described above. One component of Hypothesis 1 predicts that presence of anxiety will
increase the chance of participants reporting memory complaints. In this example, the
two variables Anxiety (1 = present; 2 = little or not present) and Memory Complaints (1
= present; 2 = few or not present) can be viewed in the cross-classification in Table l.
The hypothesis is the probability pm that anxiety and memory complaints are both
present. Alternatives include the probability pm that anxiety is present but memory
complaints are not; the probability pm that anxiety is not present but memory complaints
are; and the probability p22 that neither anxiety or memory complaints is present. The
hypothesis states that the odds Q; = p” / pm that participants with anxiety have memory
complaints is greater than the odds Q; = p21 / p22 that participants with no anxiety have
memory complaints. The hypothesis is tested using the odds ratio 9 = Q] / Q; to

determine if it is better than chance. If the odds ratio 0 is greater than 1, we can say that

26

it is more likely that participants with anxiety report memory complaints than participants
with little or no anxiety. Thus, using odds ratios, we determined the probabilities of
Hypotheses l, 3, and 4. Each of the five hypothesis will be addressed individually in this
section.

Hypothesis 1: Participants who endorse anxiety and depression symptoms will be
more likely to report more memory complaints and show poorer memory performance
than participants who do not endorse anxiety and depression symptoms. One option is to
analyze this data categorically. This 2 x 2 x 2 x 2 cross-classification of the four
variables Anxiety (1 = present; 2 = little or not present), Depression (1 = present; 2 =
little or not present), Memory Complaints (1 = present; 2 = few or not present), and
Memory Performance (1 = poor; 2 = good) produced a pattern for each participant. For
each of the variables, we determined cut off scores to indicate the presence or absence of
the conditions. Using odds ratios, we were able to test each participant’s pattern with the
hypothesis. For example, pm, is the probability of displaying the presence of anxiety,
little or no depression, few or no memory complaints, and poor memory performance and
was compared to the probability (p ,1 1 I).

Hypothesis 2: Participants reporting higher levels of anxiety at the time of testing
will score lower on the memory test than participants reporting lower levels of anxiety
symptoms at the time of testing. This relationship was measured using the scores from
the STAI (State) and the CVLT. We used a t-test to compare regression parameters.

Hypothesis 3: Participation in memory-training workshops is expected to reduce
memory complaints as well as increase scores on the memory functioning test. We

analyzed this data categorically by using odds ratios. This 2 x 2 x 2 cross-classification

27

of the three variables Participation (l = yes; 2 = no), Memory Complaints on Pretest (1 =
yes; 2 = no), and Memory Complaints on Posttest (1 = yes; 2 = no) produced a pattern for
each participant. Also, a 2 x 2 x 2 cross-classification of the three variables Participation
(l = yes; 2 = no), Memory Performance on Pretest (1 = poor; 2 = good), and Memory
Performance on Posttest (1 = poor; 2 = good) produced a pattern for each participant.
Again we used cut off scores to indicate the presence or absence of the conditions. We
were able to test each participant’s pattern with the hypothesis (p112). Also, we were able
to compare pattern pm with pattern p m, or pattern [71/2 with pattern p212.

Hypothesis 4: Gender differences are expected with anxiety symptoms affecting

 

memory complaints more in women than in men. In addition, women are expected to
report more symptoms of anxiety than men report. We used odds ratios to compare
Memory Complaints of men and Memory Complaints of women. Also, we used odds
ratios to compare Anxiety of men and Anxiety of women.

Hypothesis 5: Level of education differences are expected with individuals with

 

higher levels of education showing fewer memory complaints and better memory
performance than individuals with lower levels of education, independent of symptoms
of anxiety and depression. We analyzed this data using ANOVA. The scores for
Memory Complaints and scores for Memory Performance was compared for each Level
of Education variable (1 = High School or less/ 12 years or less; 2 = College/ 13 to 16
years; 3 = Graduate Work/l 7 years or more). We expected Memory Complaints to

decrease with more education and Memory Performance to increase with more education.

28

Missing Values

The data set contained missing values in all variables. One option in research
with missing data is to disregard incomplete data sets. However, there are a number of
statistical procedures available to replace missing data in such a way that allows the use
of all variables in a data set. In this current study, missing data were replaced as
continuous data before categorization with cut-off scores. To replace missing values,
NORM for Windows 95/98/NT "Multiple imputation of incomplete multivariate data
under a normal model" Version 2.03 by J. L. Schafer was used. The data set was entered
into the program. Missing values were generated, imputed, entered, and used in data
analysis. By imputing missing data, we were able to include all participants in data

analysis.

29

RESULTS
Hypothesis 1

This hypothesis has two components: the effect of anxiety and depression
symptoms on memory complaints and the effect of anxiety and depression symptoms on
memory performance. The first component of the hypothesis (participants endorsing
anxiety and depression symptoms will report more memory complaints) was supported
(see Table 3). The second component of the hypothesis (participants endorsing anxiety
and depression symptoms will show poorer memory performance) was not supported (see
Table 4).

Based on the above cut-off scores for anxiety, depression, and memory
complaints, participants were categorized into one of two groups: Present or Not-
Present. For memory performance, participants were categorized in either the Poor or
Good group. For the anxiety variable, 45 participants were placed into the Present group
while 55 were placed into the Not-Present group. For the depression variable, 23
participants were placed into the Present group while 77 were placed into the Not-Present
group. For the memory complaints variable, 35 participants were categorized into the
Present group while 65 were categorized into the Not-Present group. Finally, for the
memory performance variable, 18 participants were categorized into the Poor group
while 78 were categorized into the Good group.

In examining the effects of anxiety, the odds of Poor memory performance were
1.81 greater when anxiety was not present than when anxiety was present, though this

result is not significant (z-score = 1.09; p > .05). The odds of Present memory

30

complaints were 3.09 times greater when anxiety was present than when anxiety was not
present. This result is statistically significant (z-score = 2.59; p < .05).

In examining the effects of depression, the odds of Poor memory performance
were 1.61 times greater when depression was not present than when depression was
present, though this result is not significant (z-score = 0.70; p > .05). The odds of Present
memory complaints were 5.34 times greater when depression was present than when
depression was not present. This result is statistically significant (z-score = 3.29; p <
.05).

Hypothesis 2

It was predicted that the level of anxiety at the time of testing would impact the
level of memory performance, with participants reporting higher levels of anxiety
performing worse than participants reporting lower levels of anxiety. This hypothesis
was not supported (see Table 5).

At the time of testing, 32 participants reported higher levels of anxiety as
indicated by the STAI-State measure, while 68 participants reported lower levels of
anxiety. Scores from the CVLT were compared between the higher and lower levels.
The group of participants reporting higher levels of anxiety obtained a mean of 6.13 (SD
= 1.76) while the group of participants reporting lower levels of anxiety obtained a mean
of 6.26 (SD = 2.00). The group of participants reporting higher levels of anxiety
performed worse than the group of participants reporting lower levels of anxiety though

the difference was not found to be significant (F = .727; p > .05).

31

Hypothesis 3

This hypothesis has two components. The first component (participation in
memory-training workshops was expected to decrease in memory complaints) was not
supported (see Table 6). The second component (participation in memory-training
workshops was expected to increase memory performance) was not supported (see Table
7).

Fifty-nine participants attended memory-training workshops prior to the second
testing while 41 did not participate prior to the second testing and serve as a control
group, as described earlier. Of the 59 memory-training workshop participants, 22
showed memory complaints during pre-testing while 37 did not show memory
complaints during pre-testing. At post-testing, 17 participants showed memory
complaints while 42 did not. Of the 41 control participants, 13 showed memory
complaints during pre-testing while 28 did not. At post—testing, 6 participants showed
memory complaints while 35 did not. The odds of present memory complaints at post-
testing are 2.36 times greater when participants attended memory-training workshops
than when they did not participate in memory-training workshops, though this result is
not significant (z-score = 1.63; p > .05).

Of the 59 memory-training workshop participants, 15 showed poor memory
performance at pre-testing, while 44 showed good memory performance. At post-testing,
10 participants showed poor memory performance while 49 showed good memory
performance. Of the 41 control participants, three showed poor memory performance at
pre-testing while 38 showed good memory performance. At post-testing, eight

participants showed poor memory performance while 33 showed good memory

32

performance. The odds of poor memory performance at post-testing is 1.19 times greater
when participants did not attend memory training workshops than when they participated
in memory-training, though this result is not significant (z-score = 0.33; p > .05).
Hypothesis 4

This hypothesis concerns gender differences and has two components. The first
component (women will report more memory complaints than men) was not supported
(see Table 8). The second component (women will report higher levels of anxiety than
men) was supported (see Table 9).

There were 61 female participants and 39 male participants. Of the 61 female
participants, 20 showed memory complaints while 41 did not. Of the 39 male
participants, 15 showed memory complaints while 24 did not. Male participants were
1.28 times more likely to report memory complaints than women, though this result was
not significant (z-score = 0.58; p > .05).

Of the 61 female participants, 33 reported high levels of anxiety while 28 did not.
Of the 39 male participants, 12 reported high levels of anxiety while 27 did not. Female
participants were 2.65 times more likely to report high levels of anxiety than males. This
result is significant (z-score = 2.26; p < .05).

Hypothesis 5

 

This hypothesis concerns differences between levels of education and has two
components. The first component (participants with higher levels of education will show
fewer memory complaints than participants with lower levels of education) was not

supported (see Table 10). The second component (participants with higher levels of

33

education will show better memory performance than participants with lower levels of
education) was not supported (see Table 11).

There were three levels of education: High School (up to 12 years of education),
College (between 13 and 16 years of education), and Graduate Work (over 17 years of
education). There were 29 participants in the High School group, 37 participants in the
College group, and 34 participants in the Graduate Work group. There were no
significant differences between level of education groups and scores on the MAC-S
Ability subtest (E = 1.27; p > .05). Higher scores on the MAC-S indicate fewer
complaints. The High School group obtained a mean of 55.97 (SD = 8.53). The College
group obtained a mean of 55.46 (SD = 10.94). The Graduate group obtained a mean of
59.00 (SD = 9.95). The Graduate group showed fewer complaints though this result is
not significant. Also, there were no significant differences between level of education
groups and scores on the CVLT (E = 1.58; p > .05). The High School group obtained a
mean of 6.72 (SD = 1.75). The College group obtained a mean of 5.89 (SD = 2.01). The
Graduate group obtained a mean of 6.15 (SD = 1.92). Level of education did not
significantly predict memory complaints or memory performance.

General Findings

Overall, 45% of participants reported anxiety symptoms compared to 23% who
reported depression symptoms. In looking at comorbid anxiety and depression, 18% of
participants showed symptoms of anxiety and depression. Overall, 18% of participants
showed poor memory performance. Overall, 35% of participants showed memory

complaints. Of memory-training participants, 25% showed poor memory performance at

34

pre-testing as compared to 17% at post-testing. Of memory-training participants, 37%

showed memory complaints at pre-testing compared to 29% at post-testing.

35

DISCUSSION

Anxiety and Demssion

 

Almost half of the participants in this study reported significant levels of anxiety
and nearly a quarter of participants reported significant levels of depression. These
percentages are higher than the prevalence rates of the anxiety disorders and depressive
disorders reported in previous research. Ohayon, Shapiro, and Kennedy (2000) reported
a 6.9% prevalence for mood disorders and 9.3% prevalence for anxiety disorders in the
general population. Stanley, Roberts, Bourland, and Novy (2001) reported a prevalence
of 1.3% for anxiety disorders and 2.3% for depression in adults age 60 and older in a
primary care setting. One explanation is that this study examined symptoms of anxiety
and depression in community dwelling older adults, not in a clinical setting. Individuals
can have symptoms of these disorders that are troublesome or uncomfortable, but not
severe enough to meet criteria for diagnosis.

About a fifth of participants scored above the cut-offs for both anxiety and
depression. One explanation of this finding is that the symptoms of anxiety and
depression can overlap. That is, both anxiety and depression share general negative
affective components, such as poor concentration, restlessness, and irritable mood. In
addition, both anxiety and depression share general physical symptoms, such as fatigue
and sleep disturbances. These physical and affective components are often associated
with disturbances in memory.

MemomComplaints and Memory Performance
The distinction between these elements of memory is simple. Complaints refer to

the subjective reports from the participants regarding how they believe their memory

36

ability compares with their peers while performance refers to the objective display of
memory ability. It was hypothesized that both complaints and performance would be
affected by the presence of anxiety and depression symptoms. Results show that for both
anxiety and depression, memory performance was not significantly impaired. However,
for both anxiety and depression, memory complaints were significantly higher when
participants’ scores were higher than cut-off scores. One explanation for the appearance
that memory performance was not affected by mood is that the degree of mood
disturbances was determined by symptoms and not clinical diagnosis. Perhaps the
participants were not experiencing mood disturbances that were strong enough to impact
objective ability. For memory complaints, however, participants who reported symptoms
of anxiety and/or depression may be more likely to report that there is something wrong
with their memory ability.
Gender Differences

It was hypothesized that female participants would report more memory
complaints and more anxiety symptoms than male participants. Results showed that
female participants reported significantly higher levels of anxiety than male participants.
This finding is consistent with previous research (Fuentes & Cox, 2000; Morin et al.,
1999; Ohayon, Shapiro, & Kennedy, 2000). However, results showed that for memory
complaints, there was no gender difference. Given the previous research on gender
differences for anxiety combined with previous research suggesting that participants
reporting symptoms of anxiety also report memory complaints more so than participants
who do not report symptoms anxiety, it was hypothesized that female participants would

report more memory complaints in this current investigation. The data did not support

37

this hypothesis. The tendency, though not statistically significant, was for male
participants to report more memory complaints than female participants. One
explanation is that there were more women in the study than men. A statistical hope is
that there are equal numbers of men and women in any particular study that examines
gender differences. With more male participants in the study, there might have been
more variability in male responses to memory complaint measures. In addition, more
participants reported symptoms of anxiety (45% of participants) than memory complaints
(3 5% of participants). Since there were more overall reporting on anxiety symptoms, it is
more likely that gender differences appear for anxiety. That is, since more participants
reported anxiety symptoms overall, there is a better chance that there will be more
women within that group.

Other research has presented similar results in that no gender differences were
found for memory complaints. Derouesne, Lacomblex, Thibault, and LePoncin (1999)
found no gender differences in adult over 50 years old. Blazer, Hays, F illenbaum, and
Gold (1997) also found no significant gender difference for memory complaints in adults
65 years or older. Like this current study, Blazer et al. (1997) had significantly more
men than women in their study. Additional research has shown no gender differences for
memory complaints in younger and older adults. Ponds, van Boxtel, and Jolles (2000)
found no gender differences for self-reported cognitive abilities (viz., attention, decision
making, memory, and mental speed) in adults ages 24 to 86 years. Also, Bassett and
Folstein (1993) found no gender differences for memory complaints in adults ages 18 to

92 years.

38

Education

There were no differences between levels of education for memory complaints or
for memory performance. One explanation is that these results may be misleading since
participants in each group were compared to participants in the other groups. That is, the
assumption in this hypothesis is that memory performance declines with age and that
education can serve as a protective factor. However, since no premorbid memory level
was tested, we cannot make comparisons between each participants memory ability at
age 20, for example, to the memory ability at age 60. If a participant with more
education shows the same memory ability as a participant with less education, we cannot
know if there has been decline with age. That is, the participant with more education
may have had a better memory ability at age 20 than the participant with less education
had at age 20. When these two participants are compared at age 60, however, they show
no difference. The participant with more education has experienced a significant decline
while the participant with less education has not. In this example, education did not
serve to protect memory ability. In this study, however, we have no way of knowing
whether this decline is the case or not. A longitudinal study is needed to examine this
question. The results of this study suggest that level of education does not have an
impact on participants’ ability to recall word lists.

Van der Linden, Philippot, and Heinen (1997) found that participants (ages 20-80
years) with higher levels of education demonstrated better memory performance on the
CVLT (General Verbal Learning measure) than participants with lower levels of
education. That effect decreased but was still significant when they controlled for

vocabulary knowledge. In addition, Van der Linden et al. (1997) found that for the short-

39

delay recall factor of the CVLT, participants with higher levels of education performed
better than those with lower levels of education. However, education did not produce
statistically significant differences for the forgetting rate factor and the learning strategy
factor of the CVLT. Also, Van der Linden et al. found no significant differences with
regard to education for memory complaints. That is, level of education did not have an
effect on participants’ subjective memory evaluation as measured a memory self-
assessment questionnaire. Age, however, did have an effect for memory complaints with
older participants (ages 60-80 years) reporting more problems with memory than younger
participants (ages 20-30 years). Van der Linden et al. proposed that there is a difference
between level of education and intelligence with respect to protective factors for
memory. They suggested that level of education should be separated from verbal
intelligence or vocabulary knowledge when examining memory performance in older
adults.

Schmand, Smit, Geerlings, and Lindeboom (1997) also encourage a distinction
between level of education and intelligence when studying older adults. In examining the
risk factors for dementia, Schmand et al. (1997) found that vocabulary knowledge was
significantly better than education in predicting cognitive decline.

Memory Training

It was hypothesized that memory training would decrease memory complaints
and increase memory performance. The results did not support the components of this
hypothesis. Fewer participants reported memory complaints at post-testing after
participating in memory training workshops. In addition, fewer participants showed poor

memory performance at post-testing after participating in memory training workshops.

40

These trends, however, were not statistically significant. Control participants showed a
similar trend for memory complaints, though not statistically significant. However, more
control participants showed poor memory performance at post-testing, though not
statistically significant either. One explanation for these results is that the memory
improving techniques presented in the workshops require a great deal of practice and
effort in order to be effective. The time of post-testing (within one week after
workshops) may not allow for enough practice for participants to master the techniques.
Also, there was not a questionnaire to determine whether workshops participants were
practicing or utilizing the memory training techniques. Future research on memory
training may benefit from incorporating this type of questionnaire to determine whether
participants are practicing the memory techniques presented in workshops. Kramer and
Willis (2002) indicated that older adults can benefit from cognitive training and
suggested that new techniques be implemented that address deficits specific to the needs
older adults. However, they stated that most research in training with older adults is
completed in a format that requires participants to practice techniques on their own. This
procedure relies on compliance with instruction to practice, as in this current study.
Also, Baltes and Raykov (1996) provided six sessions of cognitive training to older
adults in the area of figural relations problems. The training sessions were conducted in
such a way that practicing at home was not required. They found that older adults
benefited from this type of training.
Results Found in Predicted Direction

There are three components to the hypotheses in which the results showed that the

differences were not significant but the tendency matched the components of the

41

hypotheses. These findings, while not statistically significant, are worthy of discussion.
First, Hypothesis 2 stated that the level of anxiety at the time of testing (state anxiety)
would negatively impact the level of memory performance. Results showed that the 32
participants with higher state anxiety scored lower than the 68 participants with lower
state anxiety. However, the difference in scores between the two groups was not
statistically significant. Next, in Hypothesis 3, the second component of the hypothesis
stated that participation in memory training workshops was expected to improve memory
performance. Results showed that at post-testing there were five fewer participants than
at pre-testing who showed poor memory performance after participating in memory
training workshops. For the group who did not participate in memory training
workshops, there were five more participants showing poor memory performance at post-
testing than at pre-testing. At least five participants of the memory training workshops
seemed to have improved memory performance while five participants of those who did
not participate seemed to have shown a decline in memory performance. Finally, the first
component of Hypothesis 5 stated that participants with higher levels of education would
report fewer memory complaints that participants with less education. While the results
were not significant, the tendency was for participants with 17 or more years of education
to report fewer memory complaints than participants with some college and for
participants with less than a high school education. These results for these three
components of the hypotheses that were not significant but in the predicted direction may
have been strengthened with different methodology. The following section discusses

these issues.

42

Methodological Concerns / Limitations of Study

There are methodological issues which may have had an effect on the outcomes
of this study. Each of the issues will be discussed in this section to explain results that
did not support hypotheses. Of primary concern in this present study was that the raw
data was dichotomized for use in odds ratio calculations. That is, cut off scores were set
to place participants into one of two categories. For example, the memory performance
cut off score was set at four. Participants scoring four or below were placed in the “poor”
performance category. There were 18 participants in this category (out of 100
participants). Those participants scoring above four were placed in the “normal or good”
performance category. There were 82 participants in this category (out of 100
participants). Within this category were participants scoring between five and ten. We
treated all participants in the “normal or good” group as the same when there might have
been differences for participants showing better memory performance with respect to any
of the other variables that were tested. By using two categories, we were unable to
compare participants with poor memory performance to participants with particularly
good memory performance. In the same way, we dichotomized other variables: anxiety,
depression, and memory complaints. It is possible that using three categories (e. g., low,
medium, and high) might have produced different results because we would have been
able to compare the “low” and “high” groups for the hypotheses presented. Also, with
respect to dichotomizing data, we may have found different results if the data were
continuous through regression analysis.

Additional methodological concerns can be raised regarding the sample, with

issues of sample size and gender being of particular interest. The sample size in this

43

study was 100. There were more women than men (61 women and 39 men). A larger
sample size with more even distribution of female and male participants might have made
a difference in the results by having more participants in each category. With the issues
raised regarding dichotomizing the data and increasing the number of categories per
variable, more participants would be needed to have enough participants in each
category. Related to overall sample size is the size of the group of participants who
endorsed symptoms of both depression and anxiety. This group (18% of all participants)
is also too small to be able to generalize regarding comorbidity of anxiety and depression
in older adults.

Self-selection of participants might also have had an effect on outcomes.
Participants were recruited through advertisements that offered “Mood and Memory
Workshops” and that encouraged participation for individuals who might be concerned
about their memory as they age. The characteristics of individuals who responded may
be different than individuals who chose not to respond. That is, individuals who
responded might be more concerned about aging, memory, or mood. This concern may
have an impact on anxiety, depression, and memory complaints scores. Also, these
individuals may be more aware of memory issues, which can also have an effect on
memory complaints. By responding to the advertisement, individuals are suggesting that
they do have concerns about their memory. They may have already experienced
problems associated with memory, which would impact memory complaints as well as
memory performance scores. Finally, these individuals have demonstrated that they have

the motivation as well as the ability to participate in workshops. It is possible that

44

individuals who chose not to respond may be more representative of the population of
older adults.

Results of this study show that participation in workshops did not have a
significant effect on reducing memory complaints or improving memory performance.
There are several methodological issues to discuss regarding these results. Fifiy nine
participants completed workshops and returned for post-testing. Thirteen participants
completed pre-testing and post-testing prior to attending workshops. These participants
were designed to serve as control participants. Another 28 participants were pre-tested
and began participation in workshops. Of these participants, some did not complete
workshops and did not return for post-testing while others completed workshops but did
not return for post-testing. Regardless of the reason they did not return for post-testing,
there may be a difference in characteristics of these participants as compared to
participants who did complete all parts of the study. We can speculate as to what these
characteristics are. It may be that participants who did not return for post-testing were
not satisfied with the workshops. Or, they were not interested in post-testing because
they were only interested in the workshops. Perhaps they dropped out of workshops for a
variety of reasons (e. g., inconvenient times or location, negative perceptions of the
workshops, or apathy). Nevertheless, these participants who began workshops but were
not post-tested are likely to have different motivation levels than participants who
completed workshops and post-testing.

Another consideration for an explanation of the results regarding the workshops
involves the type of workshop that participants attended. Of the 59 participants who

participated in workshops, 22 were Relaxation and 37 were Attention. Both types of

45

group presented the same information regarding memory training techniques and
strategies as well as the same amount of time devoted to memory training. Both groups
presented additional information regarding techniques of relaxation and techniques for
improving attention. However, the amount of time spent on these techniques depended
on the focus of the group. That is, the Relaxation group spent more time on relaxation
techniques and less time on techniques for improving attention. The Attention group
spent more time on activities that focused on improving attention with less time spent on
relaxation techniques. During data analysis, we did not distinguish between group type.
The hypothesis regarding participation in memory training focused on the memory
complaints and memory performance, not anxiety. However, it is possible that by
analyzing the groups together, we missed the effect of group type. The Relaxation group
might be better at decreasing anxiety but not improving memory. In a similar way, the
Attention group might be better at improving memory but not decreasing anxiety. If
these possibilities are true, then by placing both group types together, we may have
neutralized the effects of each group with the other. Our hypothesis regarding memory
training, however, was focused on participation in memory training workshops. We
proposed that the participation was the important factor, not group type. This idea may
help to explain the reason that we did not find significant results for participation in
memory training.
Broader Implications

There were five hypothesis with a combined nine components for this research
study. Two of those nine components were supported by the data. Three components

were in the predicted direction, though not significant. There are some important

46

outcomes of this research. With 45% of participants endorsing symptoms of anxiety,
there is evidence that older adults experience anxiety more than we expected. Medical
and psychological professionals should be urged to consider further investigation of how
anxiety impacts the health and well-being of older adults. When older adults seek
medical attention, it may be beneficial for physicians to take time to inquire about
anxiety symptoms. While the results of this study did not support the effect of memory
performance, previous research supports the notion that anxiety can have negative effects
on health concerns for older adults. Further research is needed to investigate these
concerns.

Most of the older adults in this study did not show poor performance on memory
tests. This news is good since loss of memory is a concern for older adults. In addition
to inquiring about anxiety, medical and psychological professionals should be urged to
perform memory check ups for older adult patients. These memory check ups can serve
to inform clinicians on the level of memory performance for older adults. In addition,
since older adults show concern for memory loss in the form of memory complaints,
memory check ups can provide objective evidence that can serve to alleviate concerns for
older adults. Further, if memory check ups show negative results, clinicians can make
appropriate referrals for testing and treatment.

Finally, gender differences with respect to anxiety symptoms showed that women
tend to experience and/or report symptoms of anxiety more frequently than men do.
Medical and psychological professionals should consider paying attention to the

emotional needs of older women.

47

APPENDIX

48

APPENDIX A

Memory Training Workshop Description

Session 1:

a)
b)

C)

d)
e)
f)

g)

Introduction and discussion of participant’s present memory problems
Relaxation and mental imagery exercise

Review and discussion handouts: Memory awareness and What happens to your

 

memory as you get older?

Mnemonic training for word lists (handout Method of Loci)

 

Practice exercise for Method of Loci
Mood discussion (handout: Memoryand self concept)

Homework assignment: construction of individual locations for Method of Loci

Session 2

a)
b)
C)
d)
e)
f)

a)
b)
C)

d)

Group discussion of previous session (e. g., homework, handouts, and methods)
Relaxation and mental imagery exercise

Mnemonic training for word lists (review of Method of Loci)

Second practice exercise for Method of Loci

Mood discussion (handout: Self-change skills)

Homework assignment: 16 —word list to be memorized with Method of Loci

Session 3

Group discussion of previous session (e. g., homework, handouts, and methods)
Relaxation and mental imagery exercise
Mnemonic training for paragraphs (handout: Strategies for recall of text)

Practice exercise with Preview-Question-Read-Summarize-Test (PQRST) method)

49

e) Mood discussion (handout: Stress and attention and Pleasant activities and
depression)

f) Homework assignment: practice exercises for Method of Loci and PQRST

Session 4

a) Group discussion of previous session (e.g., homework, handouts, and methods)

b) Relaxation and mental imagery exercise

c) Mnemonic training for paragraphs (review PQRST method)

d) Mood discussion (handout: Positive thinking)

e) Homework assignment: practice exercises for PQRST

Session 5

a) Group discussion of previous session (e. g., homework, handouts, and methods)

b) Relaxation and mental imagery exercise

c) Mnemonic training for names (handout: How to remember names)

d) Mood discussion (handout: Assertiveness)

e) Homework assignment: practice exercises for PQRST and name-face association

Session 6

a) Group discussion of previous session (e.g., homework, handouts, and methods)

b) Relaxation and mental imagery exercise

c) Mnemonic training for names (review names-face association mental imagery with
slide Show exercise)

(1) Handout: External strategies for memory recall

e) Homework assignment: practice exercises for Method of Loci and name-face task

50

Session 7

a) Group discussion of previous session (e.g., homework, handouts, and methods)

b) Relaxation and mental imagery exercise

c) Mnemonic training for names (handouts: How to remember names and Maintaining
your memory and attention power)

d) Mood discussion (handout: feelings about workshop and obtained abilities)

e) Homework assignment: arrangements for post-testing

51

Table 1

2 x 2 Cross-Classification of Anxiety and Memory Complaints

 

 

 

Memory
Complaints
Present Not
Present
Yes pl 1 P12
Presence of Anxiety
NO p21 P22

 

52

Table 2
Cut-off Scores for Measures

 

 

1 2

STAI

State 2 37 (present) S 36 (not present)

Trait 2 46 (present) S 45 (not present)
PSWQ 2 53 (present) S 52 (not present)
TAS (present) (not present)
GDS 2 10 (present) S 9 (not present)
BDI 2. 16 (present) S 15 (not present)
TDS (present) (not present)
CVLT S 4 (poor) 2 5 (good)
MAC-S S 52 (poor) 2 53 (good)
Levels of education 1 = Up to 12 years of education

2 = Between 13 and 16 years of education

3 = Over 17 years of education

53

Table 3

Results of Hypothesis 1, Component 1

 

 

Anxiety

 

Complaints

 

Present
Not Present

Present

Not Present

 

22

23

 

 

l3

 

42

 

 

 

 

Depression

 

Complaints

 

 

Present
Not Present

Present

Not Present

 

15

8

 

 

20

 

57

 

 

54

odds
0.96
0.31

odds
1.88
0.35

odds ratio
3.09

odds ratio
5.34

z-score
2.59

z-score
3.29

Table 4

Results of Hypothesis 1, Component 2

 

 

 

 

 

 

 

 

 

 

 

 

Anxiety jerformance
Poor Good
Present 6 39
Not Present 12 43
Depression Performance
Poor Good
Present 3 20
Not Present 15 62

 

 

 

 

55

odds
0.15
0.28

odds
0.15
0.24

odds ratio
1.81

odds ratio
1 .61

z-score
1.09

z-score
0.70

. "I,

 

l-A‘F“ ‘

 

 

 

 

 

 

 

 

Table 5
Results of Hypothesis 2
State Anxiety N Mean SD
CVLT Present 32 6. 13 1.76
Not Present 68 6.26 2.00
F = 0.727 p > .05

 

56

.. _HWM'¢._

Table 6

Results of Hypothesis 3, Component 1

 

[Participation IComplaints

 

Yes
No

 

 

 

Present Not Present
1 7 42
6 35

 

 

 

57

odds
0.40
0.17

odds ratio
2.36

z-score
1 .63

 

Table 7

Results of Hypothesis 3, Component 2

 

 

 

 

 

 

Participation Performance
Present Not Present
Yes 1 0 49
No 8 33

 

 

 

 

58

odds
0.20
0.24

odds ratio
1. l 9

z-score
0.33

Table 8

Results of Hypothesis 4, Component 1

 

 

 

 

 

Gender Complaints J
Present Not Present
Male 1 5 24
Female 20 4 1

 

 

 

 

59

odds
0.63
0.49

odds ratio
1.28

z-score
0.58

Table 9

Results of Hypothesis 4, Component 2

 

 

 

 

 

Gender Anxiety J
Present Not Present
Male 1 2 27
Female 33 28

 

 

 

 

6O

odds
0.44
1.18

odds ratio
2.65

z-score
2.26

Table 10

Results of Hypothesis 5, Component 1

 

 

 

 

 

 

 

 

 

 

Complaints
Education N Mean SD
MAC-S 12 or fewer years 29 55.97 8.53
13-16 years 37 55.46 10.94
17 or more years 34 59.00 9.95
F = 1.27 p > .05

 

 

 

61

 

Table 1 1

Results of Hypothesis 5, Component 2

 

 

 

 

 

 

 

 

 

 

Performance
Education N Mean SD
CVLT 12 or fewer years 29 6.72 1.75
13-16 years 37 5.89 2.01
17 or more years 34 6.15 1.92
[F = 1.58 p > .05

 

62

 

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