Cognitive Complaints in Memory Clinic Patients and in Depressive Patients

An Interpretative Phenomenological Analysis

Lisa Miebach, MSc; Steffen Wolfsgruber, PhD; Ingo Frommann, Dipl. Psych.; Klaus Fließbach, PhD; Frank Jessen, MD; Rachel Buckley, PhD; Michael Wagner, PhD

Disclosures

Gerontologist. 2019;59(2):290-302. 

In This Article

Abstract and Introduction

Abstract

Background and Objectives: Cognitive complaints are discussed as early signs of Alzheimer's disease (AD). However, they are also very common in cognitively normal older adults and in patients with depression. Qualitative, interview-based approaches might be useful to identify those features of cognitive complaints specific for the experiences of cognitive decline in preclinical or prodromal AD versus those complaints typically reported by depressed patients.

Research Design and Methods: A semi-structured interview was administered to 21 cognitively normal older adults (HC), 18 nondemented memory clinic patients (MC), and 11 patients with a major depression (MD), all above 55 years. Interpretative phenomenological analysis (IPA) was applied to the interview transcripts to develop emerging complaint themes in each group. To identify thematic correspondence and possibly novel, hitherto unappreciated themes, the extracted complaint categories were compared with the neurocognitive domains in the DSM-5 and the content of the Everyday Cognition questionnaire (E-Cog).

Results: IPA yielded 18 cognitive complaint categories in MC, 10 in depressive patients, and 10 categories in the HC group. Several themes were common across groups, but some were group-specific, for example, spatial disorientation was only reported in MC patients. Some of these MC-specific themes were neither represented by DSM-5 domains nor by the E-Cog.

Discussion and Implications: We report a comprehensive qualitative description of cognitive complaints in old age which could help to develop questionnaires or structured interviews to better assess AD-related subjective cognitive decline. This may help to increase specificity in selecting high-risk subjects in research settings and improve clinical judgment of diverse cognitive complaints types mentioned by their patients.

Introduction

Mounting evidence suggests that cognitive complaints are a sensitive early behavioral marker of Alzheimer's disease (AD) (Jessen et al., 2014; Mitchell, Beaumont, Ferguson, Yadegarfar, & Stubbs, 2014). Many studies associated subjective cognitive complaints with an increased risk of future cognitive decline (Koppara et al., 2015) and an increased likelihood of abnormal AD biomarkers (Amariglio et al., 2012; Chételat et al., 2010; Perrotin, Mormino, Madison, Hayenga, & Jagust, 2012; Saykin et al., 2006; Wolfsgruber et al., 2015). Other findings suggest associations between memory complaints and depressive symptoms (Balash et al., 2013; Balash, Mordechovich, Shabtai, Merims, & Giladi, 2010; Schmand, Jonker, Geerlings, & Lindeboom, 1997). Based on current findings, attention is now turning to the issue of sensitivity and specificity of cognitive complaints with regard to AD (Rabin et al., 2015). A particularly salient issue relates to the notion of what components of complaints are "AD-like" and which may be more representative of a mood disorder or of aging in general.

Primarily, subjective cognitive decline (SCD) has been defined as the "subjective experience of worsening cognitive function in comparison with earlier performance" (Jessen et al., 2014). The SCD Initiative (SCD-I) recently published criteria for the implementation of SCD in research studies (Molinuevo et al., 2016). With regard to the core clinical criteria of mild cognitive impairment (MCI) proposed by the NIA-AA diagnostic framework, evidence of concerns should relate to decline in cognition (Albert et al., 2011). However, much of the early literature has focused only on concerns related to memory. Current methods of measurement of cognitive complaints are as heterogeneous as the different criteria (Abdulrab & Heun, 2008; Jessen et al., 2014; Jonker, Geerlings, & Schmand, 2000; Rabin et al., 2015). There is a lack of well evaluated measures for SCD and the theoretical and empirical development of the existing scales is mostly not well documented. Common instruments such as the Cognitive Failures Questionnaire (CFQ; Broadbent, Cooper, FitzGerald, & Parkes, 1982), the Cognitive Function Instrument (CFI; Amariglio et al., 2015), the Everyday Cognition Scale (E-Cog; Farias et al., 2008) or the Assessment of memory complaint in age-associated memory impairment (MAC-Q; Crook, Feher, & Larrabee, 1992) are based on expert knowledge, theoretical considerations, statistical methods or diagnostic criteria. Importantly, neither of these instruments was developed by a systematic qualitative study of cognitive complaints. This raises the possibility that some complaint themes reflecting cognitive decline due to neurodegenerative processes are not well represented in current instruments.

Qualitative methods are advantageous as they address highly nuanced and contextualized aspects of subjective experiences (Smith, Flowers, & Larkin, 2009). Investigations of MCI patients' self-awareness and experience of their diagnosis have revealed that qualitative approaches may well lead to a more in-depth view than a quantitative measurement (Lingler et al., 2006; Roberts & Clare, 2013). There is already a substantial literature dealing with the qualitative exploration of the lived experience of people with dementia (Clare, Roth, Pratt, & Clare, 2005; Clare, Rowlands, Bruce, Surr, & Downs, 2008; Harman & Clare, 2006; Johansson, Marcusson, & Wressle, 2015; Sabat & Harré, 1992). However, the approach of a qualitative description of the experiences underlying cognitive complaints has only recently been pursued with patients with MCI or SCD.

Buckley and colleagues (2015) first examined the subjective experience of memory change in cognitively normal older adults and MCI patients. Using an inductive thematic approach, 12 themes were extracted (Buckley et al., 2015). Many themes were more commonly expressed in MCI patients, and some were also sensitive to β-amyloid (Aβ) load. While the memory complaint categories derived in this study address the different ways of "how" different people express their complaints, the aspect of "what type of" complaints they have is a different one. Quantitative studies dealing with this question are dependent on current measurements and thus suffer from the inherent operationalization problem mentioned above (La Joie et al., 2016).

The aim of the current study was to take a "fresh look" at the range of cognitive complaints in older adults. We explored these complaints in cognitively normal older adults (HC), memory clinic patients (MC), and patients with major depressive disorder (MD) using a qualitative method called interpretative phenomenological analysis (IPA). IPA is particularly suited to capture subjective experiences associated with a given phenomenon (Smith et al., 2009). Complaint themes extracted with IPA were compared between the three groups to determine common and group-specific cognitive complaint symptomatology. Themes specific for the MC group (i.e., for potential preclinical/prodromal AD) were also qualitatively compared with established SCD measurements, to determine whether these fully reflect the subjective cognitive complaint experience in nondemented patients at risk for AD.

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