1. Jen Yates, Linda Clare, Bob Woods and CFAS Wales
Mild cognitive impairment and mood: The role of subjective memory complaints. A cross-sectional study from CFAS-Wales
Jen Yates, Linda Clare, Bob Woods and CFAS Wales
Bangor University

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

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

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

5. Research questions:
Are people with MCI more likely to have symptoms of anxiety or depression than people with normal cognitive functioning?
Are people with SMC more likely to report symptoms of anxiety or depression than people without SMC?
Do SMC mediate the relationship between cognitive impairment and symptoms of anxiety or depression?

6. Methods: Design Cognitive Function and Ageing Study Wales (CFAS Wales)
Longitudinal population based study involving participants from two areas of Wales
Participants took part in a structured questionnaire covering various aspects of health, social and cognitive functioning
This paper presents baseline data
MRC CFAS conducted in 1990 onwards
Over participants originally screened
2640 selected for detailed assessment which included cognitive measures and measures of mood

7. Methods: Participants
People aged over 65 years and living in Gwynedd/ Ynys Mon and Swansea
Randomly sampled between 2011 and 2013
Participants were excluded from the analysis if they had a diagnosis of dementia (n=129), impaired ADLs (n=52) or other cognitive impairment no dementia (OCIND; n=152)
3137 participants
Details of participants were obtained from GP records

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

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

10. Results: Descriptives
1050 (33.1%) of participants reported SMC
200 (6.3%) participants met criteria for MCI and 329 (10.4%) were categorised as MCIW
Table 1: Sample characteristics for participants with and without SMC
No SMC
SMC
Total (%)
Age mean (SD)
74.34 (6.89)
74.34 (6.79)
MMSE mean (SD)
27.55 (2.19)
27.22 (2.30)
CAMCOG mean (SD)
85.20 (10.65)
84.83 (8.47)
Years in FT Education mean (SD)
11.73 (2.69)
11.73 (2.83)
Female N (%)
1205 (56.8)
524 (50.1)
1729 (54.5)
With anxiety N (%)
79 (3.7)
84 (8.0)
163 (5.1)
Without anxiety N (%)
2044 (96.3)
966 (92.0)
3010 (94.9)
With depression N (%)
431 (20.3)
357 (34.0
788 (24.8)
Without depression N (%)
1692 (79.7)
693 (66.0)
2385 (75.2)
2123 (66.9)
1050 (33.1)
3173 (100)
Level of SMC and cognitive impairment according to our definitions is relatively high
Few differences otherwise between people with SMC and without in terms of age, education, mmse.
Less people at follow-up for reasons such as elective withdrawal, death and moving out of study area.

11. Results: Are people with MCI more likely to have anxiety or depression?
The odds of having symptoms of anxiety or depression were significantly increased in participants classified as MCI
The odds of having symptoms of anxiety or depression were not significantly changed in participants classified as MCIW
Participants without cognitive impairment did not show a significant change in odds
Only difference between MCI and MCIW participants is presence of SMC
Depression increased at follow-up for those who had MCI at baseline and at follow-up: Note – these are not necessarily the same people as people can change categories in any direction.

12. Results: Are people with SMC more likely to have anxiety or depression?
The odds of having symptoms of anxiety or depression were higher in participants who reported SMC compared to those who did not report SMC
SMC increased the odds of anxiety and depression even in participants without cognitive impairment
Having anxiety or depression at baseline might lead to the development of SMC after two-years

13. Results: Do SMC mediate the relationship between cognition and symptoms of anxiety?
Cognition used as a dichotomous variable created by an age-, education, and gender adjusted median split of the total CAMCOG score
Mediation analyses suggest that the association between cognition and anxiety is significantly partially mediated by the presence of SMC (z’=-2.29, p=.021)
Having anxiety or depression at baseline might lead to the development of SMC after two-years
SMC
Cognition
Anxiety

14. Results: Do SMC mediate the relationship between cognition and symptoms of depression?
Cognition used as a dichotomous variable created by an age-, education, and gender adjusted median split of the total CAMCOG score
Mediation analyses suggest that the association between cognition and depression is significantly partially mediated by the presence of SMC (z’=-2.48, p=.013)
Having anxiety or depression at baseline might lead to the development of SMC after two-years
SMC
Cognition
Depression

15. Discussion: Main findings
Symptoms of anxiety and depression were increased in people with MCI, but are not changed in people categorised as MCIW or participants without cognitive impairment
Symptoms of anxiety and depression were increased in people with SMC, regardless of cognitive status
Suggests that anxiety and depression may be related to SMC rather than cognitive impairment.

16. Discussion: Limitations
Questions used in the interview to assess anxiety and depression may not be sensitive enough to draw out less severe or
less frequent instances of symptoms
Number of participants reporting anxiety was small
Response rates for CFAS Wales were approximately 50%, which may suggest that the sample may not be entirely representative
SMC are reported through a positive answer to two items which may not fully capture all levels of subjective memory
complaints
The numbers of people reporting anxiety at baseline with or without SMC were just 8 and 23, so very small.
Participants can move from MCI back to no cognitive impairment for example, people don’t progress in a linear fashion which does make seeing changes quite difficult
Some participants who have SMC at baseline no longer report it at follow-up
We did include AGECAT level 2 to account for milder symptoms

17. Discussion: Strengths
CAMCOG is a well-established screening tool
The MCIW category is very useful in directly comparing with participants classified as MCI
AGECAT scores of 2 and above considered to be cases to take account of milder and less frequent symptoms
This research builds on previous research using the MRC CFAS dataset which found similar findings and adds to it with the use
of mediation
CAMCOG is used in many studies and in clinical practice
MCIW category allows a direct comparison between people with SMC and without as the participants are similar in terms of other criteria that they meet.
Due to the sampling nature from GP surgery lists and method of approach it ensured the sample was very representative and did not consist of people who had been identified through service/hospital use, as can be common in studies of older people.

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

19. Discussion: Subjective cognitive impairment?
Potentially an incipient stage of dementia before MCI when the patient is aware but the doctor is not
Cognitive performance is within the normal range on neuropsychological tests
Previous research suggests a common patterns of cellular loss in the hippocampus between depression, anxiety and Alzheimer’s disease
People with subjective cognitive impairment are at higher risk of depression and further cognitive decline
Research in this area is emerging
Early intervention in cognitive problems can help to slow down the development of further cognitive decline. People diagnosed as having MCI progress to dementia at a rate of 10-12% annually compared to people with normal cognitive functioning at a rate of 3% annually.
SMC may be a marker for other issues, such as anxiety or depression. As such, older people reporting memory problems could be asked about their mood as well as their memory to see if help could be offered.
Due to unstable nature of MCI and SMC, more frequent time points could used in future research to see how quickly or how often participants change cognitive status

20. For further information please email j.yates@bangor.ac.uk
Thank you
Any questions?
For further information please