Subjective Memory Complaints in Relation to
Anxiety and Test Performance of Patients Recovering from Severe Acute
Respiratory Syndrome in Hong Kong.
Alma Au1
Iris Chan2
Patrick Li2
Chan Yiu Han 2
Johnny Chan2
1 Department of Applied Social Science, Hong Kong Polytechnic University, Hong Kong, China.
2
Department of
Medicine, Queen Elizabeth Hospital, Hong Kong, China.
Citation:
Au A., Chan, I,.,
Li P, Han C.Y., & Chan, J.
(2006). Subjective Memory
Complaints in Relation to Anxiety and Test Performance of Patients
Recovering from Severe Acute Respiratory Syndrome in Hong Kong.
International Journal
of Psychosocial
Rehabilitation. 10 (1)
Reprint requests and correspondence should
be sent to
Alma Au. Ph.D.
Department of Applied Social Science
Hong Kong Polytechnic University
Hung Hom
Hong Kong
China
Email: ssalma@inet.polyu.edu.hk
Abstract
Memory problems have been
reported during steroid administration. The
existing literature suggests that many of these effects are transient
and
reversible. The purpose of the study was to explore the associations of
subjective memory complaint with objective test performance and
emotional state
in recovering SARS patients.
Method:
Twenty-three
patients aged between 20 to 34 were divided into 2 groups:
those who reported trouble with their memory and those who did not.
Cognitive
functioning including general intelligence and memory was assessed
using
subtests of the Wechsler Adult Intelligence and Memory Scales and the
Hong Kong
List Learning Test. Mood was assessed using the Hospital Anxiety and
Depression
Scale.
Results:
No significant
difference was identified between the two groups in
cognitive test performance. Furthermore, results obtained did not
suggest the
presence of any systematic cognitive impairment in both groups.
However, the
group reporting memory trouble was found to significantly score higher
on an
anxiety scale.
Conclusion:
Results
suggested the possibility of a relationship between anxiety and
subjective memory complaint. Results also suggest that subjective
memory
complaints need to be assessed and treated in the context of the
overall
adjustment in individuals trying to recover from a sudden and severe
illness.
Specifically, psychological intervention may be needed to help patients
to
overcome their anxiety about their functional competence in the process
of
psychosocial rehabilitation.
Key Words: SARS, memory, subjective
complaint, test
performance, anxiety
Introduction
Severe Acute Respiratory Syndrome (SARS) is
an acute atypical pneumonia believed to be caused by a previously
unknown
coronavirus and is responsible for the first pandemic of the 21st
century (Peiris et al., 2003). Hong Kong, China,
remains one of the most severely affected areas. With the infectious
nature of
this new disease, SARS can have many behavioral and emotional
implications for
recovering patients. After recovering initially in the physical sense,
other
challenges begin to surface. These include uncertainties about side
effects of medication,
longer-term effects of the illness, the ability to return to previous
occupation and to handle interpersonal relationships. Uncertainty and
stigmatization are prominent themes in the longer-term emotional
adjustment in
SARS (Maunder et al., 2003; Gorodzinsky, 2003, Au et al., 2004).
A treatment protocol including a
combination of ribavirin and systemic steroids was adopted from the
beginning
of the epidemic and the protocol is currently being reviewed (Chan et
al.,
2003; So et al., 2003; Yuji, 2003). Memory problems have been reported
during
steroid administration. This ranges from mild problems in verbal memory
to
severe dementia. The existing literature suggests that many of these
effects
are transient and reversible (Brown & Chandler, 2003; Newcomer et
al.,
1999). However, some recovering SARS patients receiving outpatient
follow-up
care in our specialist clinic have continued to report a subjective
sense of
memory difficulties. So far, there is no published data on the
cognitive
functioning of recovering Severe Acute Respiratory Syndrome (SARS)
patients who
have received steroid therapy in Hong
Kong. Thus, the purpose of the
study was to explore the relationships
between subjective memory complaint, objective cognitive test
performance and
emotional state for these patients.
Method
Subjects
and Procedure
Twenty-three discharged SARS patients (aged
between 20-34) were recruited from the Outpatient Clinic of Queen
Elizabeth
Hospital. The age group chosen was based primarily on the availability
of local
test norms for that particular age group which is also the primary
reference
group of the established Wechsler scales (Wechsler, 1981). At the time
of their
regularly scheduled appointments at the clinic, all patients of this
age range
were invited to an interview with the clinical psychologist. After
briefly
outlining the purpose of the assessment and obtaining written consent,
patients
were invited to complete self-administered questionnaires. All
consenting
patients were seen about 1 to 2 months after discharge from hospital.
One
patient did not turn up for the scheduled appointment stating that
there was no
need for assessment.
Demographic characteristics were collected
through the questionnaire. Illness and treatment related information
including
medication was obtained from the medical record. For the subjective
memory
complaint, each subject was asked “Do you have trouble with your
memory?” The
answer “yes” or “no” was recorded. This one question has been
previously proven
to be a sensitive and valid method to assess memory complaint in
Chinese-speaking population (Wang et al., 2000). Based on the response
to this
question, 12 patients were allocated to the group with subjective
memory
complaint (SMC+) and 11 were allocated to the group without subjective
memory
complaint (SMC-).
Measures
The Chinese translation of the Wechsler
Adult Intelligence Scale-Revised (WAIS-R) was used to assess general
intellectual functioning (Wechsler, 1981; Chan et al., 2000). As for
testing of
memory, the Hong Kong List Learning Test (HKLTT) was used to assess
verbal
memory (Chan & Kwok, 1999; Au et al., 2003) and the Visual
Reproduction
(VR) subtest of the Wechsler Memory Scale-Revised (WMS-R) was used to
assess to
visual memory (Wechsler, 1987).
The WAIS-R subtests administered included
Digit Span, Arithmetic, Similarities, Picture Completion, Block Design
and
Digit Symbol. The selection of subtests was based on the seven-subtest
short
form version of WAIS-R that has generally been found to be a
cost-effective and
accurate method to estimate overall intellectual functioning (Axelrod
&
Paolo, 1998). However, the Information
subtest was omitted as the questions in the original American version
were
judged to be not representative enough for the local culture. In terms
of the
dimensions of the underlying abilities measured, Similarities has been
found to
load on the “verbal” factor. Block Design, Picture Completion and Digit
Symbol
loaded on the “perceptual” factor. Finally, Digit Span and Arithmetic
loaded on
the third factor termed “freedom-from-distractibility” of
“attention/concentration” (Leckliter et al., 1986). The HKLTT yields
measures
of immediate recall of the auditory-verbal learning of a 16-word list
over
three trials. It also involves a delayed recall of the list after 30
minutes.
Local norms are available for the chosen WAIS-R subtests and the HKLTT.
Requiring the drawing from memory simple geometric designs that are
each
exposed for ten seconds, the WMS-R (VR) produced a score for immediate
recall and
a score for delayed recall after 30 minutes. There are no local norms
for the
WMS-R (VR). However, with its primarily non-verbal content, the culture
loading
is considered minimized.
Emotional state was monitored using the
14-item Hospital Anxiety and Depression Scale (HADS) to provide
measures of
anxiety and depression (Zigmond & Snaith, 1983). Each item is
scored from 0
to 3. Total scores range from 0 to 21 for the Anxiety subscale and also
for the
Depression subscale. The HADS has been widely used to monitor mood
changes in
medical and neurological patients in Hong Kong (Au et al., 2002).
Data analysis
The WAIS-R yielded six raw scores, one for
each subtest. The VR of the WMS-R yielded two measures: immediate
recall and 30-minute
delayed recall. For the HKLTT, learning over three trials was added up
to form
a total learning score. The HKLTT delayed recall was based on the
number of
words recalled after 30 minutes. The raw scores of the WAIS-R and the
HKLTT
were converted into percentiles according to the available Hong Kong
Chinese
norms (Chan et al., 2000, Chan & Kwok, 1999). The
scores for the WMS-R (VR) were converted
into percentiles according to the norms given in the manual. The HADS
yielded
scores for 14-items from which two independent subscale scores was
calculated
for Anxiety and Depression. Subjects were divided into two subgroups
according
to the presence or absence of subjective memory complaint. T-tests were
performed to investigate group differences on emotional state and
objective
measures of cognitive functioning. The SPSS programs for Windows,
Release 7.0,
was used for all analysis.
RESULTS
Demographic characteristics and medical
information of the two groups are summarized in Table 1. The 2 groups
are largely
comparable in the variables described. However, the age was higher in
the group
with subjective memory complaint than the group without [t(22) = -2.80, p < 0.05]. Results
on the WAIS-R, HKLTT and WMS-R (VR) are summarized in Table 2. Results
on the
HADS are summarized in Table 3. No significant differences between the
2 groups
were identified in the objective test performance. Furthermore, the
test scores
for both groups are all in the normal range.
As for the HADS, there were also no significant in terms of the
Anxiety
and Depression subscale scores. Again, the scores for both groups are
in the
normal range. However, the group with subjective memory complaint was
found to
score significantly higher in Item 3 [t(22) =
-2.35, p < 0.05]. For this item, patients
were asked to
rate in what degree they “got a sort of frightened feeling as if
something
awful is about to happen”. Higher scores on the item indicated greater
anxiety.
Table
1. Demographic
characteristics and medical information of the two groups: patients
with
subjective memory complaint (SMC+) versus those without (SMC-)
___________________________________________________________________________
SMC+
Group (n=12)
SMC- Group
(n=11)
Mean
(SD)
Mean
(SD)
___________________________________________________________________________
Age
30.92
(2.07)
26.92
(4.30)*
Sex
Male
3
7
Female
9
4
Education
13.83
(2.79)
13.73
(2.61)
Employment
Employed
1
1
Unemployed
11
10
Marital status
Single
5
6
Married
6
5
Widowed
1
Time since onset (days)
71.00
(12.64)
86.00
(21.95)
Time since discharge (days)
43.67
(16.85)
56.10
(21.31)
Period of hospitalization
(days)
27.18
(12.24)
27.80
(17.00)
Need for Admission into
Intensive Care Unit
Yes
2
2
No
10
9
Need for Intubation
Yes
3
2
No
9
9
Prenisolone equivalence (mg)
2059.08 (1045.13)
1840.86
(1006.50)
___________________________________________________________________________________
*p < 0.05
Table
2. Objective test performance of the two groups: patients with
subjective
memory complaint (SMC+) versus those without (SMC-)
<>
SMC+
Group (n=12) SMC- Group (n=11)
Mean
(SD)
Mean
(SD)
<>___________________________________________________________________________
<>Wechsler Adult Intelligence Scale-Revised
<>(In percentile)
<>Digit Span
83.82
(28.03)
96.85
( 7.41)
<>Arithmetic
47.50 (28.09)
50.55
(27.92)
<>Similarities
47.00
(28.08)
41.27
(26.05)
<>Picture Completion
43.68
(22.06)
50.55
(29.62)
<>Block Design
49.17
(27.89)
59.45
(27.70)
<>Digit Symbol
59.50
(29.44)
54.91
(33.50)
<>Hong Kong
List Learning Test
<>(In percentile)
<>Total Learning
58.61
(16.48)
55.90
(23.64)
<>Delayed Recall
59.17
(26.20)
62.00
(24.20)
<>Wechsler Memory
Scale-Revised (Visual Reproduction)
<> (In
percentile)
<>Immediate Recall
83.08 (15.79)
90.91 (11.36)
<>Delayed Recall
80.75
(21.62)
87.73
(17.41)
<>___________________________________________________________________________
<>
<>____________________________________________________________________________________________________________
<>Table 3. Emotional state profile of
the two groups: patients with subjective memory complaint (SMC+) versus
those without (SMC-)
<>
_____________________________________________________________________________________________________________
SMC+
Group (n=12) SMC- Group
(n=11)
Mean
(SD)
Mean
(SD)
___________________________________________________________________________
Hospital Anxiety and Depression Scale
(Raw scores)
Anxiety
5.42
(3.00)
3.45
(2.73)
Depression
3.50
(3.85)
2.18
(2.40)
Item 1
0.92
(0.67)
0.45
(0.69)
Item 2
0.67
(0.89)
0.45
(0.52)
Item 3
1.08
(0.79)
0.36
(0.67)*
Item 4
0.08
(0.29)
0.18
(0.40)
Item 5
0.75
(0.75)
0.81
(0.60)
Item 6
0.58
(0.90)
0.45
(0.52)
Item 7
0.83
(0.72)
0.64
(0.50)
Item 8
1.08
(0.51)
0.82
(0.75)
Item 9
0.75
(0.45)
0.45
(0.52)
Item 10
0.25
(0.45)
0.18
(0.40)
Item 11
0.42
(0.51)
0.27(0.47)
Item 12
0.67
(0.98)
0.18
(0.40)
Item 13
0.75
(0.75)
0.64
(0.67)
Item 14
0.17
(0.39)
0.00 (0.00)
___________________________________________________________________________
*p < 0.05
Conclusion
The study explored the relationships of
subjective memory complaint with objective test performance and
emotional state
in 23 recovering SARS patients aged between 20 to 34. Comparing a group
with
subjective memory complaint and a group without the complaint, results
did not
reveal any significant differences in the objective test performance in
terms
of intellectual functioning and memory. The cognitive test scores and
the mood
scores for both groups are all in the normal range. However, the group
with
subjective memory complaint scored significantly higher on an anxiety
item that
described “a sort of frightened feeling as if something awful is about
to
happen.” This is a rather interesting finding as apprehensive
expectation is
the cardinal feature of anxiety according to the Diagnostic and
Statistical
Manual of Mental Disorders. These results would suggest the subjective
memory
complaint could be related to anxiety (APA, 1994).
Discrepancies between subjective memory
complaint and cognitive test performance in neurological patients have
been
frequently reported (Piazzini et al., 2001). The present study is
perhaps the
first to document this discrepancy in recovering SARS patients.
Findings
suggest that subjective memory complaint in these patients may be
related to
anxiety. However, the present study has certain limitations. The
subject number
was relatively small and the age group was confined to younger
patients. The
choice of the age range was initially based on the availability of
local test
norms and the relative lack of other possible neurological
complications in
older adults.
To conclude, the present study highlighted
the possibility of the relationship between emotional factors and the
subjective sense of memory competence. A severe illness like SARS can
cause
major disruptions to activities in daily living. Furthermore SARS
patients are
also faced with social prejudice causing them difficulties in getting
the
support when they need them most. The subjective sense of frailty and
fatigue
can lower the sense of personal control to return to the previous
functioning
and lifestyle. Levels of anxiety and depression have been found to
correlate
with the subjective sense of mastery in local epilepsy patients (Au et
al.,
2002). Although future studies need to
clarify the relationship between emotions and subjective memory, the
findings
of the present study reinforced the need to take into account the
emotional
state in the recovery in SARS patients. Results of the present study
suggest
that subjective memory complaints need to be assessed and treated in
the context
of the overall adjustment in individuals trying to recover from a
sudden and
severe illness. Specifically, psychological intervention may be needed
to help
patients to overcome their anxiety about their functional competence in
psychosocial rehabilitation.
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